Citation Nr: 18159218 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 16-31 997 DATE: December 18, 2018 ORDER As new and material evidence has been received, the claim of entitlement to service connection for bilateral knee pain is reopened; the appeal is granted to this extent only. Entitlement to service connection for flat feet is denied. Entitlement to service connection for an acquired psychiatric disorder, other than posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for a pain disorder is denied. Entitlement to a rating in excess of 10 percent for tinnitus is denied. REMANDED Entitlement to an increased evaluation for DDD of the lumbosacral spine, currently evaluated as 20 percent disabling, is remanded. Entitlement to an increased evaluation for radiculopathy affecting the right lower extremity, currently evaluated as 20 percent disabling, is remanded. Entitlement to service connection for bilateral knee pain (claimed as impairment of the knees and degenerative joint disease (DJD) of the knees), to include as secondary to service-connected DDD of the lumbosacral spine and radiculopathy affecting the right lower extremity, is remanded. Entitlement to service connection for heart disease, to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for carotid artery disease, to include as secondary to service-connected PTSD, is remanded. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected PTSD, DDD of the lumbosacral spine and radiculopathy affecting the right lower extremity, is remanded. Entitlement to service connection for insomnia, to include as secondary to service-connected PTSD, DDD of the lumbosacral spine and radiculopathy affecting the right lower extremity, is remanded. FINDINGS OF FACT 1. The Veteran’s claim of entitlement to service connection for bilateral knee pain, was denied in a December 1996 rating decision; the Veteran did not appeal the decision. 2. Evidence received since the December 1996 rating decision is neither cumulative or redundant, relates to an unestablished fact necessary to establish the claim, and raises a reasonable possibility of substantiating the claim. 3. 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 flat feet. 4. The preponderance of the evidence is against finding that an acquired psychiatric disorder, other than PTSD, began during active service, or is otherwise related to an in-service injury, event, or disease. 5. The preponderance of the evidence is against finding that a pain disorder began during active service, or is otherwise related to an in-service injury, event, or disease. 6. The Veteran is already in receipt of the maximum schedular rating for tinnitus. CONCLUSIONS OF LAW 1. The December 1996 rating decision that denied entitlement to service connection for bilateral knee pain is final; however, new and material evidence has been received to reopen this matter. 38 U.S.C. §§ 5108, 7105(c); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 2. The criteria for service connection for flat feet are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for an acquired psychiatric disorder, other than PTSD, are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for service connection for pain disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 5. The criteria for the assignment of a disability evaluation higher than 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.87, Diagnostic Code 6260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1973 to November 1976 and from August 1979 to August 1996. This matter comes before the Board on appeal from June 2013 and September 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. As a preliminary matter, the Board notes that in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant’s description of the claim; symptoms described; and the information submitted or developed in support of the claim. In light of the Court’s decision in Clemons, the Board has recharacterized the issues of entitlement to service connection for anxiety and depression as entitlement to service connection for an acquired psychiatric disorder, other than PTSD. Also, the Board acknowledges that in the September 2013 Notice of Disagreement (NOD), June 2016 substantive appeal (VA Form 9) and April 2017 Statement in Support of Claim, the Veteran contended that his VA examination was inadequate, but did not specify which examination he deemed inadequate. In the September 2013 NOD, the Veteran asserted that the VA examiner did not adequately review his claims file or “show any concern about the exam” as the examination lasted “5 to 6 minutes”. Here, the record indicates that the Veteran participated in several VA examinations between January 2007 and February 2017. The results of those examinations have been included in the claims file for review. The examinations involved a review of the Veteran’s medical records; thorough, in-person examinations; and clinical findings based on the above. The Board observes that the Veteran has not expressed any specific deficiencies with a specific examination, other than his opinion that an examiner did not adequately review his claims file and that an examination lasted between 5 to 6 minutes. The Board finds that the VA examiners are qualified medical professionals who have the training, knowledge, and expertise on which they relied to conduct the Veteran’s examinations and to provide clinical findings used in deciding these claims. Thus, the Board finds the Veteran’s VA examinations adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). New and Material Evidence Generally, a claim which has been denied in an unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). An exception to this rule is 38 U.S.C. § 5108, which provides that if a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). VA must review all of the evidence submitted since the last final rating decision in order to determine whether the claim may be reopened. See Hickson v. West, 12 Vet. App. 247, 251 (1999). For the limited purpose of determining whether new and material evidence has been submitted, the credibility of the newly submitted evidence is presumed. See Justus v. Prinicipi, 3 Vet. App. 510, 513 (1992); see also Kutscherousky v. West, 12 Vet. App. 369, 371 (1999) (per curium) (holding that the “presumption of credibility” doctrine continues to be precedent). The presumption is rebuttable when the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). New and material evidence has been submitted for the claim of entitlement to service connection for bilateral knee pain By way of brief procedural history, the claim of service connection for bilateral knee pain was originally denied by a December 1996 rating decision because the RO determined that the Veteran’s service treatment records (STRs) did not indicate that the Veteran had a diagnosis of a chronic underlying bilateral knee disorder, as such, he did not have a well-grounded claim. In a December 27, 1996 letter, the RO notified the Veteran of its decision but, the Veteran did not initiate an appeal of the rating decision within one year, nor was any new and material evidence received within a year. 38 C.F.R. § 3.156(b). Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011) (finding that VA must determine whether evidence received during the appeal period after a decision contains new and material evidence per § 3.156(b) and failure to readjudicate the appeal after receipt of such evidence renders the decision non-final). The December 1996 rating decision is accordingly final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160(d), 20.200, 20.302, 20.1103. The Veteran subsequently sought to reopen the service connection claim for bilateral knee pain (now claimed as impairment of the knees and DJD of the knees) in September 2012. In a September 2013 rating decision, the RO denied the service connection claim as a nexus was not established between the Veteran’s bilateral knee disorder and his service. The RO considered the bilateral knee pain issue on the merits as all the elements necessary to substantiate the claim of service connection were addressed. Hickson v. Shinseki, 23 Vet. App. 394 (2010). In June 2016, the Veteran filed a substantive appeal (VA Form 9) to the Board; as such, the Board must decide the threshold issue of whether the Veteran submitted evidence that is new and material before addressing the merits of the claim. See Jackson v. Principi, 265 F. 3d 1366 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). The relevant evidence added to the record since the December 1996 rating decision (last final denial) include VA and private medical records dated from October 2007 through February 2017, an August 2013 Knee and Lower Leg Conditions Disabilities and Benefits Questionnaire (DBQ), an October 2016 Knee and Lower Leg Conditions DBQ and lay assertions included in the September 2016 VA Form 9, in which the Veteran contended that his bilateral knee disorder was due to his service-connected DDD of the lumbosacral spine and radiculopathy affecting the right lower extremity. An October 2007 VA treatment note indicated that the Veteran was diagnosed with bilateral knee arthralgia. As the Veteran has a diagnosed bilateral knee disorder and new evidence supporting the service connection claim has been submitted since the December 1996 last, final decision, the claim is reopened. Overall, the lay and clinical evidence raises a reasonable possibility of substantiating the service connection claim for bilateral knee pain and addresses a nexus to service. Presuming its credibility, this evidence is new as it was not previously submitted and/or considered by agency decision-makers and is material as it relates to an unestablished fact regarding the nexus/relationship of the Veteran’s diagnosed bilateral knee condition to his service. As such, the evidence is sufficient to reopen the service connection claim. 38 C.F.R. § 3.156(a). Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if preexisting such service, was aggravated thereby. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). Generally, to establish entitlement to service connection, a veteran must show evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the current disability and an in-service injury or disease. All three elements must be proved. See generally Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Alternatively, under 38 C.F.R. § 3.303 (b), service connection may be established for certain chronic diseases listed under 38 C.F.R. § 3.309 (a) by either (1) the existence of such a chronic disease noted during service, or during an applicable presumption period under 38 C.F.R. § 3.307, and present manifestations of that same chronic disease; or (2) where the condition noted during service is not in fact shown to be chronic or where the diagnosis of chronicity can be legitimately questioned, then a showing of continuity of symptomatology after discharge is required to support the claim of service connection. 38 C.F.R. § 3.303 (b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including psychoses, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.§ 5107 (b); 38 C.F.R. §3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for flat feet, to include as secondary to service-connected DDD of the lumbosacral spine The Veteran contends that he has flat feet because of his service, to include as due to his service-connected DDD of the lumbosacral spine. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of flat feet and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The Veteran’s STRs indicated that he did not complain of, was treated for, or diagnosed with flat feet during service. STRs indicated that the Veteran’s complaints, treatment and/or diagnoses included, but were not limited to, mild enteritis; multiple superficial skin abrasions; periodontal disease and other dental procedures; a vasectomy; left ankle sprain; dizziness and headaches. However, there was no indication of flat feet during active duty. His November 1976 separation Report of Medical Examination indicated that his feet were normal. On the Report of Medical History, he endorsed “no” for “foot trouble”. In the same fashion, the Veteran’s April 1996 retirement Report of Medical Examination indicated that his feet were normal. Again, on the Report of Medical History, he endorsed “no” for “foot trouble”. The Veteran’s post-service medical records indicate that on VA outpatient treatment in May 2006, he endorsed and was diagnosed with bilateral foot pain. Otherwise, the medical evidence of record, including April and May 2006 feet x-rays, did not indicate that the Veteran had a diagnosis of flat feet. In a March 2018 Statement in Support of Claim, the Veteran asserted that his flat feet were a result of his service-connected DDD of the lumbosacral spine. In April 2017, in support of his service connection claim, the Veteran submitted medical literature attributed to the Mayo Clinic that defined flat feet. Based on the foregoing evidence, the Board finds that service connection for flat feet is not warranted. In so finding, the Board observes that the Veteran’s STRs indicate that the Veteran did not complain of, was treated for, or diagnosed with flat feet during active duty. The Veteran’s November 1976 separation and April 1996 retirement Reports of Medical Examination indicate that his feet were normal. After separation, the Veteran reported bilateral foot pain; however, the medical evidence of record does not indicate that the Veteran has diagnosed flat feet. As highlighted above, the most probative evidence fails to demonstrate that the Veteran has had diagnosed flat feet at any time during the pendency of this appeal. Moreover, the Veteran has not presented persuasive evidence showing that he has symptoms that result in any functional impairment. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a “disability” under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). Congress specifically limited entitlement to service connection for a disease or injury to cases where the disease or injury has resulted in a disability. In the absence of a proof of present disability there can be no claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). While the Veteran believes he has a current diagnosis of flat feet, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education. Jandreau, surpa. Consequently, the Board gives more probative weight to the medical evidence of record. For the foregoing reasons, the Board finds that service connection for flat feet must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. 2. Entitlement to service connection for an acquired psychiatric disorder, other than PTSD The Veteran contends that he has an anxiety disorder and depression due to service. The Veteran is already service connected for PTSD and assigned a 50 percent rating. PTSD is an anxiety disorder. Moreover, the Veteran’s symptoms of depression and anxiety are symptoms of his PTSD. See, e.g., VA examination report dated in February 2017. There is no persuasive evidence of an acquired psychiatric disorder other than PTSD linked to in-service events. The Board recognizes the Veteran’s belief that he is entitled to service connection for an acquired psychiatric disorder, other than PTSD. Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, the Veteran is not considered competent to provide a nexus opinion. See Kahana, supra. The Board highlights that competent statements are limited to that which the Veteran has observed and is within the realm of his personal knowledge; such knowledge comes to the Veteran through use of his senses-that which is heard, felt, seen, smelled or tasted. See Layno, supra. It is within the Veteran’s realm of personal knowledge whether he experienced symptoms related to the claimed disability. It is not shown, however, that the Veteran possesses the medical expertise necessary to provide a probative opinion on a complex medical matter such as the etiology of an acquired psychiatric disorder. See Jandreau, supra. For the foregoing reasons, the Board finds that service connection for an acquired psychiatric disorder, other than PTSD must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. 3. Entitlement to service connection for a pain disorder The Veteran contends that he has a pain disorder because of his service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran a diagnosed pain disorder, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The Veteran’s STRs indicated that the Veteran did not complain of, was treated for, or diagnosed with a pain disorder during active duty. As previously discussed, the Veteran complained of and was treated for multiple conditions, none of them involved a pain disorder. His November 1976 and April 1996 separation/retirement Reports of Medical Examination did not indicate that the Veteran was diagnosed with a pain disorder. His post-service medical records indicated that in May 2013, he was diagnosed with chronic pain, many years after separation. A September 2013 private treatment record noted his chronic pain syndrome diagnosis. Otherwise, his post-service medical records indicate that the Veteran did not report or receive treatment for a pain disorder. Based on the foregoing evidence, the Board finds that service connection for a pain disorder is not warranted. In so finding, the Board observes that the Veteran’s STRs indicated that he did not complain of, was treated for or was diagnosed with a pain disorder during active duty. The Veteran’s November 1976 and April 1996 separation/retirement Reports of Medical examination did not indicate that he was diagnosed with a pain disorder. Furthermore, the clinical evidence of record indicates that the Veteran was diagnosed with chronic pain in 2013, many years after separation. The clinical evidence indicates that the Veteran did not exhibit symptoms of, or was diagnosed with a pain disorder until several years after his separation from military service, which suggests that the pain disorder was not incurred in or related to his military service. The Board recognizes the Veteran’s belief that he is entitled to service connection for a pain disorder. However, as discussed previously, the Veteran is not considered competent to provide a nexus opinion involving complex medical matters. See Kahana, supra. For the foregoing reasons, the Board finds that service connection for a pain disorder must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, supra. Increased Rating Entitlement to a rating in excess of 10 percent for tinnitus is denied. The Veteran seeks a rating in excess of 10 percent for his tinnitus. Under Diagnostic Code 6260, a 10 percent rating is warranted for recurrent tinnitus. A higher schedular evaluation is not available. Per Note (2), only a single evaluation is to be assigned for recurrent tinnitus, whether the sound is perceived in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic 6260. The Veteran was last afforded a VA Hearing Loss and Tinnitus examination and an Ear Conditions (Vestibular and Infections Conditions) examination in May 2013. During the Ear Conditions examination, the Veteran endorsed a “high-pitched whistling” and occasional pain in his left ear. The Veteran also reported staggering; however, the examiner noted that the Veteran’s gait was normal. The Veteran is separately service-connected for residuals of perforated left ear tympanic membrane. The Veteran is currently in receipt of the maximum rating for tinnitus. Moreover, no other condition has been clinically associated with his tinnitus, and the Veteran is not competent to opine on a nexus between general complained of symptoms and an internal physical process affecting the ears. Accordingly, his claim is denied. REASONS FOR REMAND 1. Entitlement to an increased evaluation for DDD of the lumbosacral spine, currently evaluated as 20 percent disabling and entitlement to an increased rating for radiculopathy affecting the right lower extremity, currently evaluated as 20 percent disabling, are remanded. The Veteran was last provided a VA examination in conjunction with his service-connected DDD of the lumbosacral spine and radiculopathy affecting the right lower extremity in February 2017. The Court held in Correia v. McDonald, 28 Vet. App. 158 (2016), that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. A review of the claims file reveals that the prior VA examination report includes only active range of motion findings and does not include range of motion findings for passive range of motion. It also does not specify whether the results are weight-bearing or nonweight-bearing. As the previous examination report does not fully satisfy the requirements of Correia and 38 C.F.R. § 4.59, a new examination is necessary to decide the claim. 2. Entitlement to service connection for bilateral knee pain (claimed as impairment of the knees and DJD of the knees), to include as secondary to DDD of the lumbosacral spine and radiculopathy affecting the right lower extremity, is remanded. In a June 2016 VA Form 9, the Veteran asserted that his bilateral knee pain (claimed as impairment of the knees and DJD of the knees) pain is aggravated by his service-connected DDD of the lumbosacral spine and radiculopathy affecting the right lower extremity. In an October 2016 medical opinion, the VA examiner did not discuss any nexus/relationship between the Veteran’s diagnosed bilateral knee disorder and his service-connected radiculopathy affecting the right lower extremity. As such, an addendum medical opinion is needed to decide the appeal. 3. Entitlement to service connection for heart disease and carotid artery disease, to include as secondary to service-connected PTSD, is remanded. In several statements, the Veteran contended that he has heart disease and carotid artery disease because of his service-connected PTSD. In April 2017 and March 2018, in support of his claim, the Veteran submitted medical literature that addressed the relationship between depression and heart disease. Considering the above, addendum medical opinions are needed to decide the appeal. 4. Entitlement to service connection for obstructive sleep apnea and insomnia, to include as secondary to service-connected PTSD, DDD of the lumbosacral spine and radiculopathy affecting the right lower extremity, is remanded. In the March 2014 NOD, the Veteran contended that his obstructive sleep apnea and insomnia were attributable to his “depression, anxiety, back condition and radiculopathy”. In April 2017, in support of his service connection claim, the Veteran submitted medical literature that addressed the link between sleep apnea and depression and the causes of chronic insomnia, namely, depression, anxiety and chronic stress. In a March 2018 Statement in Support of Claim, the Veteran asserted that his insomnia was due to “PTSD and other service connected disability and . . . should be rated by itself”. Considering the above, an addendum medical opinion is needed to decide the appeal. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to evaluate the service-connected DDD of the lumbosacral spine and radiculopathy affecting the right lower extremity. The Veteran’s claims folder must be reviewed by the examiner. (a) In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree at which pain begins. (b) Pursuant to Correia v. McDonald, the examination should record the results of range of motion testing for pain in the lumbosacral spine on BOTH active and passive motion AND in weight-bearing and nonweight-bearing. If the lumbosacral spine cannot be tested on “weight-bearing,” then the examiner must specifically indicate that such testing cannot be done. (c) The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups assessed in terms of the degree of additional range of motion loss. In regard to flare-ups (pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017)) if the Veteran is not currently experiencing a flare-up, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran’s functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. [The Board recognizes the difficulty in making such determinations but requests that the examiner provide his or her best estimate based on the examination findings and statements of the Veteran.] 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s bilateral knee pain (claimed as impairment of the knees and DJD of the knees) is at least as likely as not proximately due or aggravated beyond its natural progression by the Veteran’s service-connected radiculopathy affecting the right lower extremity. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s heart disease and carotid artery disease are at least as likely as not proximately due or aggravated beyond natural progression by the Veteran’s service-connected PTSD. (a) In so opining, consider the medical literature of record entitled: “Depression and Heart Disease” and “American Heart Association: Mental Health and Heart Health”. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s obstructive sleep apnea and insomnia are at least as likely as not proximately due or aggravated beyond their natural progression by the Veteran’s service-connected PTSD, DDD of the lumbosacral spine and/or radiculopathy affecting the right lower extremity. (a) In so opining, please consider the medical literature of record entitled: “Sleep Apnea Linked to Depression”, “Sleep Apnea and Depression”, “Association of Psychiatric Disorders and Sleep Apnea in a Large Cohort” and “An Overview of Insomnia”. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Taylor, Associate Counsel