Citation Nr: 20021973 Decision Date: 03/30/20 Archive Date: 03/30/20 DOCKET NO. 19-23 728 DATE: March 30, 2020 ORDER New and material evidence having been received, the claim of entitlement to service connection for arthritis to include of the hands and low back is reopened, and to this extent only, the appeal is granted. The application to reopen the claim of service connection for bilateral hearing loss is denied. The application to reopen the claim of service connection for asthma is denied. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for high cholesterol is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection for diverticulitis, status post laparotomy (diverticulitis) is denied. Entitlement to service connection for an acquired psychiatric disorder to include bipolar disorder with anxiety and depression is granted. Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for headaches is granted. REMANDED Entitlement to service connection for arthritis to include of the bilateral hands, low back, and bilateral knees is remanded. Entitlement to service connection for frostbite is remanded. Entitlement to service connection for erectile dysfunction (ED) is remanded. REFERRED The issue of entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) has been raised by the record in November 2019 by the Veteran’s attorney. Effective March 24, 2015, a claim for benefits must be submitted on the application form prescribed by the Secretary. See 38 C.F.R. §§ 3.1(p), 3.155, 3.160. To the extent that the Veteran desires to file a claim for entitlement to a TDIU, he is advised that a complete claim on an application form prescribed by VA regulations is required. 38 C.F.R. § 3.155. FINDINGS OF FACT 1. Claims for service connection for arthritis, to include of the hands and low back, was most recently denied in an unappealed March 2014 rating decision. 2. Evidence has been received since the March 2014 rating decision, which is neither cumulative nor redundant and raises a reasonable probability of substantiating the claims for service connection for arthritis to include of the bilateral hands and low back. 3. The claims for service connection for hearing loss and asthma were most recently denied in an unappealed January 2016 rating decision. 4. The evidence submitted since the January 2016 rating decision, by itself or when considered with previous evidence of record, does not relate to an unestablished fact necessary to substantiate the claims of entitlement to service connection for hearing loss and asthma, and therefore does not raise a reasonable possibility of substantiating the claims. 5. The Veteran’s tinnitus is attributable to service. 6. High cholesterol, or hyperlipidemia, is a laboratory finding, and not a disability for Department of Veterans Affairs (VA) compensation purposes. 7. The preponderance of the evidence of record does not reflect that the Veteran’s GERD was incurred in, or is otherwise related to, service. 8. The preponderance of the evidence of record does not reflect that the Veteran’s diverticulitis, status post laparotomy, was incurred in, or is otherwise related to, service. 9. The Veteran’s psychiatric disorder, to include bipolar disorder with anxiety and depression is attributable to service. 10. Aggravation of the Veteran’s obstructive sleep apnea is secondary to the Veteran’s psychiatric disorder. 11. The Veteran’s headaches are secondary to the Veteran’s psychiatric disorder. CONCLUSIONS OF LAW 1. The March 2014 rating decision, which denied service connection for arthritis to include of the bilateral hands and low back, is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for arthritis to include of the hands and low back. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. New and material evidence has not been received since the January 2016 rating decision, regarding the claims of entitlement to service connection for hearing loss and asthma; thus, the claims are not reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The criteria for entitlement to service connection for tinnitus are met. 38 U.S.C. §§ 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a). 5. The criteria for entitlement to service connection for high cholesterol are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for entitlement to service connection for GERD are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for diverticulitis are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for entitlement to service connection for an acquired psychiatric disorder to include bipolar disorder with anxiety and depression are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125(a). 9. The criteria for service connection for obstructive sleep apnea are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(a), 3.310. 10. The criteria for service connection for headaches are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(a), 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from May 1984 to August 1987 and was a member of the United States Army National Guard of Illinois from August 1994 to July 1995. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2017 rating decision of the VA Agency of Original Jurisdiction (AOJ). The Board notes that with respect to the Veteran’s claim for arthritis, the record includes diagnoses of bilateral hand pain with possible arthritis, low back pain with degenerative joint disease and bilateral knee pain with degenerative joint disease. As service connection for the disabilities of the low back and hands have been denied by the AOJ in prior final decisions, the Board has characterized this issue as requiring new and material evidence. The Board notes that a January 2018 VA examination reflects a diagnosis of arthritis of the right foot. In July 2019, the Board remanded the issue of entitlement to service connection for a right foot disability for additional development, to include a VA examination. The issue has not been readjudicated by the AOJ. Therefore, the issue of entitlement to service connection for a right foot disability will not be addressed herein; the issue will be the subject of another Board decision, if in order. New and Material In general, VA rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.302. A finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108. New evidence is defined as evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). If the evidence is new, but not material, the inquiry ends, and the claim cannot be reopened. Smith v. West, 12 Vet. App. 312 (1999). If it is determined that new and material evidence has been submitted, the claim must be reopened. VA may then proceed to the merits of the claim on the basis of all of the evidence of record. When determining whether the submitted evidence meets the definition of new and material evidence, VA must consider whether the new evidence could, if the claim were reopened, reasonably result in substantiation of the claim. Shade v. Shinseki, 24 Vet. App. 110, 118 (2010). In Shade, the United States Court of Appeals for Veterans Claims (Court) interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold and viewed the phrase “raises a reasonable possibility of substantiating the claim” as “enabling rather than precluding reopening.” The evidence that is considered in determining whether new and material evidence has been submitted is that received by VA since the last final disallowance of the appellant’s claim on any basis. See Evans v. Brown, 9 Vet. App. 273 (1996). 1. Whether new and material evidence has been received to reopen a claim of service connection for arthritis to include of the hands and a low back condition The claim of entitlement to service connection for arthritis and arthritis of the hands was initially denied in a prior rating decision dated in March 2014, essentially based on a finding that there was no evidence that the claimed condition existed. The Veteran did not appeal this decision and it is final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Since the March 2014 rating decision, relevant additional evidence suggests a nexus between currently diagnosed bilateral hand pain possibly with osteoarthritis and military service. See October 2015 VA treatment record. This evidence, evidence not previously submitted to decisionmakers and relating to an unestablished fact necessary to substantiate the claim, raises a reasonable possibility of substantiating the claim and is thus new and material. 38 C.F.R. § 3.156(a). Thus, the claim is reopened. The claim of entitlement to service connection for a low back condition was initially denied in rating decisions dated in June 2009 and March 2014, essentially based on a finding that there was no evidence to show a lower back condition and its possible relationship to military service. The Veteran did not appeal these decisions and they are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Since the March 2014 rating decision, relevant additional evidence suggests a nexus between currently diagnosed low back disability to include degenerative joint disease and military service. See April 2016 VA treatment record. This evidence, evidence not previously submitted to decisionmakers and relating to an unestablished fact necessary to substantiate the claim, raises a reasonable possibility of substantiating the claim and is thus new and material. 38 C.F.R. § 3.156(a). Thus, the claim is reopened. As provided further below, additional development of the evidence for service connection for arthritis is required, and the claim will therefore be remanded for additional development prior to readjudication. 2. Whether new and material evidence has been received to reopen a claim of service connection for bilateral hearing loss The claim of entitlement to service connection for bilateral hearing loss was initially denied in rating decisions dated in March 2014 and January 2016, essentially based on a finding that the evidence did not show current audiometric findings which met the criteria for a grant of service connection for hearing loss. The Veteran did not appeal these decisions and they are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. After a review of the evidence, as discussed below, the Board finds that no new and material evidence has been received since the January 2016 rating decision which denied service connection for bilateral hearing loss. Relevant evidence of record at the time of the January 2016 decision included service treatment records and VA treatment records. Service treatment records include audiograms dated in May 1984, September 1984, April 1986, June 1987, and August 1992, none of which showed any hearing loss. January 2014 VA treatment records reflect a diagnosis of vertigo with component of anxiety of lack of sleep contributing. The Veteran was afforded a VA examination in February 2014, which reflected a diagnosis of bilateral sensorineural hearing loss (in the frequency range of 6000 Hz or higher frequencies). The examination did not show a hearing loss disability as defined in 38 C.F.R. § 3.385. The examiner opined that there was no permanent threshold shift (worse than reference threshold) greater than normal measurement variability at any frequency between 500 and 6000 Hz bilaterally. The examiner noted that the Veteran’s hearing was normal bilaterally at induction and hearing was normal bilaterally at separation. There was no standard threshold shift from induction to separation. The Veteran’s file was silent for any complaint of hearing loss or tinnitus. The examiner opined that the Veteran’s hearing loss was not at least as likely as not caused by or a result of military service. Since that time, the Veteran has not submitted any additional evidence regarding his claim for entitlement to service connection for bilateral hearing loss. Therefore, the Board finds that with regard to the claim of service connection for bilateral hearing loss, no new and material evidence has been received since the January 2016 rating decision, and the Veteran has not submitted evidence to establish a current bilateral hearing loss which is considered to be a disability for VA purposes. Thus, there is no sufficient new and material evidence to warrant a reopening of the claim of service connection for bilateral hearing loss. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 3. Whether new and material evidence has been received to reopen a claim of service connection for asthma The claim of entitlement to service connection for asthma was initially denied in rating decisions dated in June 2009, March 2014 and January 2016, essentially based on a finding that the Veteran’s asthma existed prior to his entrance into service and was not permanently worsened as a result of service. The Veteran did not appeal these decisions and they are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Since the January 2016 rating decision, relevant additional evidence continues to show treatment for asthma exacerbations, but the new evidence does not suggest a nexus between currently diagnosed asthma and military service. See e.g., August 2015 VA treatment record. Thus, this evidence while new and not previously submitted to decisionmakers does not relate to an unestablished fact necessary to substantiate the claim and does not raise a reasonable possibility of substantiating the claim. It is thus, not new and material and the claim is not reopened. 38 C.F.R. § 3.156(a). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). In the context of Reserve or National Guard service, the term “active military, naval, or air service” includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101 (21), (24); see also 38 C.F.R. § 3.6. Diseases or injuries incurred or aggravated while performing ACDUTRA are eligible for service connection. 38 U.S.C. §§ 101 (24), 106, 1110. In other words, when a claim is based on a period of Reserve or National Guard service, it must be shown that the individual concerned became disabled (or died) as a result of a disease or injury incurred or aggravated in the line of duty on Reserve ACDUTRA/INACDUTRA or during Federalized National Guard service. 4. Entitlement to service connection for tinnitus The Veteran seeks service connection for tinnitus, which he asserts is related to service. For Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including tinnitus, are presumed to have been incurred in or aggravated by service if manifest to a compensable degree (10 percent disabling) within one year of discharge from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease, at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). The question for the Board is whether the Veteran has a chronic disease that manifested to a compensable degree in service or within the applicable presumptive period, or whether continuity of symptomatology has existed since service. The Board has carefully reviewed the evidence of record and finds that the criteria for service connection for tinnitus have been met. The Veteran’s DD-214 indicates that the Veteran’s military occupational specialty (MOS) during service in the United States Army from May 1984 to August 1987 was infantryman, which has been shown to have a “highly probable” probability of exposure to hazardous noise. Therefore, the Board concedes that the Veteran was exposed to hazardous noise. 38 U.S.C. § 1154(a). Service treatment records do not reveal any complaint, finding, or diagnosis of hearing loss or tinnitus. January 2014 VA treatment records reflect a diagnosis of vertigo with component of anxiety of lack of sleep contributing. The Veteran reported recent episodes of suddenly experiencing dizziness and lightheadedness. The treatment provider prescribed the Veteran medication to treat his dizziness and nausea. The Veteran was afforded a VA examination in February 2014, which reflects a diagnosis of bilateral sensorineural hearing loss (in the frequency range of 6000 Hz or higher frequencies). The Veteran reported that he had recurrent tinnitus. The Veteran reported that he had been exposed to weapons (M60s and M203s), LAWs, rockets, claymore mines, grenade launchers, simulations (grenades), live fire training and ranges in the military without hearing protection. The Veteran reported periodic buzzing bilaterally. He reported that the buzzing was longstanding without a precipitating event. He reported that the buzzing occurred approximately one time a day and lasted for up to an hour per episode. The Veteran reported having dizziness (vertigo) for the past month and took prescription medication to treat the condition. The examiner opined that it was less likely as not (less than 50 percent probability) that the Veteran’s tinnitus was caused by or a result of military noise exposure. The examiner noted that the Veteran’s hearing was normal bilaterally at induction and hearing was normal bilaterally at separation. There was no standard threshold shift from induction to separation. The examiner noted that the Veteran’s file was silent for any complaint of hearing loss or tinnitus. The examiner opined that the Veteran’s tinnitus was less likely as not caused by or a result of military service. Based on the evidence as outlined above, the Board finds that the criteria for service connection for tinnitus have been met. The Board finds that based on the tinnitus complaint recorded in his February 2014 VA audiological examination and his conceded noise exposure in service the Veteran meets the first two requirements of service connection. Tinnitus claims may be supported by evidence of a continuity of symptomatology or on a presumptive basis. As noted, the Veteran reported longstanding periodic buzzing bilaterally, without a precipitating event. He is competent to report his symptoms of tinnitus, such as buzzing in the ears. Layno v. Brown, 6 Vet. App. 465, 469 (1994). See 38 C.F.R. § 3.159(a)(2). Moreover, the Board finds the Veteran’s reports of longstanding buzzing in his ear and in-service exposure to weapons to be credible. Lay statements are considered competent evidence when describing the features or symptoms of an injury or illness within the realm of personal and observable knowledge. There are certain situations in which lay evidence may suffice to prove service connection on its own merits, even in the absence of evidence in the service treatment records. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2008). In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. The Board notes that under the provisions of 38 U.S.C. § 5107(b), the benefit of the doubt is to be resolved in the claimant’s favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. Thus, resolving all reasonable doubt in favor of the Veteran and based on the medical and lay evidence of record, the Board finds that evidence of record supports a finding that service connection for tinnitus is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for high cholesterol The Veteran seeks service connection for high cholesterol, which he asserts is related to service. The Board recognizes that there are findings of elevated cholesterol in the Veteran’s medical records. Service treatment records reflect that the Veteran had an elevated cholesterol reading of 207 mg/dl in May 1987. Post service private treatment records reflect a diagnosis of hyperlipidemia and the Veteran had a cholesterol reading of 300 mg/dl in June 2013. These laboratory findings are not a disability within the meaning of the law for the purpose of compensation benefits. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Findings of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and not, in and of themselves, ratable disabilities for VA compensation purposes. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (stating in supplementary information preceding a final rule amending the criteria for evaluating endocrine system disabilities indicates that findings of hyperlipidemia, elevated triglycerides, and elevated cholesterol are laboratory results, and are not, in and of themselves, considered disabilities). In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. 6. Entitlement to service connection for GERD 7. Entitlement to service connection for diverticulitis The Veteran seeks service connection for GERD and diverticulitis, which he asserts are related to service. Service treatment records are silent as to any complaints, treatment or clinical diagnosis for GERD or diverticulitis. Post service treatment records reflect a diagnosis of GERD and diverticulitis from at least June 2013. The Board has carefully reviewed the evidence of record and finds that the criteria for service connection for GERD and service connection for diverticulitis have not been met. The Veteran has not asserted, and the evidence does not demonstrate, that the Veteran’s GERD or diverticulitis occurred during a period of qualifying service. VA “is required to reject a disability claim if the claimant fails to put forth sufficient evidence showing that the Veteran suffered an injury or incurred a disease during service.” Holton v. Shinseki, 557 F.3d 1362, 1370 (Fed. Cir. 2009). Therefore, based on the foregoing, the Board finds that the preponderance of the probative and persuasive evidence is against a finding of service connection for GERD and service connection for diverticulitis. Thus, the claims for service connection are denied. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. 8. Entitlement to service connection for an acquired psychiatric disorder The Veteran seeks service connection for a psychiatric disorder which he asserts is related to service. The Board has carefully reviewed the evidence of record and finds that the criteria for service connection for an acquired psychiatric disorder have been met. In November 2019, the Veteran’s sister stated that prior to service, the Veteran was fun, outgoing, active, social, well behaved and had a good temper. She stated that during service, she noticed changes with the Veteran’s personality. He became more depressed, withdrawn and easily angered. Following service, the Veteran became more anxious and fidgety; his anger worsened, and he began having panic attacks. The Veteran became less social and lost contact with friends and family, he was depressed all the time, lost all motivation and had trouble with his memory. In addition, she stated that the Veteran had trouble sleeping and reported that he had nightmares. He also reported that he would see and hear things. In November 2019, the Veteran’s aunt also provided a statement that was similar to the statement of the Veteran’s sister in describing the Veteran’s behavior prior to, during and after service. A September 1984 service treatment record reflects that the Veteran complained of dizziness for one hour; and the Veteran lost consciousness. The treatment provider noted that approximately 13 minutes after losing consciousness, the Veteran was alert and could walk unassisted. An April 1985 Record of Proceedings under Article 15 indicated that in January 1985 the Veteran missed the movement of his company. An August 1986 Record of Proceedings under Article 15 indicated that in August 1986 the Veteran failed to have his equipment ready for inspections. A July 1987 military personnel record reflects that the Veteran was absent without leave (AWOL) for three days. A November 1988 military personnel record reflects that the Veteran was reassigned in the reserves due to unsatisfactory participation. June 1990 military personnel records reflect that the Veteran’s unit administrator requested to discharge the Veteran from the Army Reserve. A report to suspend favorable personnel actions (FLAG) was initiated effective October 1994 due to the Veteran’s weight. A July 1995 service treatment record reflects that the Veteran reported dizziness. The treatment provider noted that the Veteran had elevated blood pressure. A July 1995 Report of Separation and Record of Service indicates that the Veteran was discharged from the United States Army National Guard of Illinois under honorable conditions for unsatisfactory participation to the United States Army Reserve Control Group (Reinforcement). See also July 1995 military personnel record. A March 2013 VA treatment record reflects a diagnosis of generalized anxiety disorder, bipolar I disorder, most recent episode hypo-manic, major depressive disorder, recurrent, moderate, alcohol abuse. The treatment provider noted that the Veteran was in the Army and joined the National Guard twice and then joined the reserves twice but did not follow through, and the Veteran was not stable due to depression. The treatment provider noted that the Veteran reported that he was placed on medication by a private treatment provider fifteen years earlier. A May 2013 VA treatment record reflects that the Veteran reported his irresponsible behavior in the military, including failing to return to base. He reported that his commanding officer could not understand how he could be such a “screw up” and yet was motivated. An August 2013 Social Security Administration (SSA) consultative psychiatric examination reflects a diagnosis of bipolar affective disorder, past chronic alcohol abuse, rule out chronic alcoholism, past chronic drug use (cocaine). The Veteran reported that he had multiple difficulties in the military. He reported that he would always get into trouble and he get extra duty. The Veteran reported that he did not report for his discharge and was put on AWOL status. The Veteran reported having both high and low mood swings since he was 17 years old in the Army. The Veteran reported that he began drinking when he was 17; and reported that he used cocaine once a month from approximately 1996 to 2000. The Veteran reported that he had been receiving treatment for his psychiatric disorder for approximately 13 years. A February 2015 VA treatment record reflects a diagnosis of bipolar I disorder and indicated that the most recent episode was in April 2013. A September 2015 VA treatment record reflects that the Veteran reported that he was frequently disciplined with Article 15’s while serving in the Army. He reported that he would be depressed and sleeping in hotel rooms and would not show up for duty. He reported that a rope broke during a training exercise and he fell into a river. The Veteran sat down at the bottom of river holding his breath until a fellow soldier rescued him. He also reported that he fell and hit his head hard against a wall while repelling off a wall during a training exercise, but he did not lose consciousness. An October 2015 VA treatment record reflects a diagnosis of bipolar I disorder and panic disorder. A July 2019 private examination reflected a diagnosis of bipolar disorder and generalized anxiety disorder. The Veteran reported that he joined the military when he was 17 and endured rough treatment and physical abuse. He reported that there was an instance where he wanted to get out of the Army and the drill sergeant roughed him up badly and he changed his mind. He also reported another incident where he and fellow soldiers were required to low crawl in their underwear over rocks. The examiner noted that the Veteran reported a pattern of physical punishment and humiliation particularly during boot camp. The Veteran reported that during service, his mood changed while he was in the military and he became violent and got into many fights. The Veteran reported that he had several failure to reports and Article 15’s and he had several incidents where he just up and left when he was expected to be somewhere. He also reported having periods in the Army where he would feel really depressed and sad, and he also had poor quality of sleep. The examiner opined that the Veteran more likely than not developed bipolar disorder and generalized anxiety disorder while in service, and those conditions had continued uninterrupted to the present. The examiner noted that the Veteran’s manic and depressive episodes persisted following his release from the military. The Veteran reported that in the late 1990s, two college professors mentioned to him that something was not right about him, which prompted him to seek treatment. See also July 2019 Mental Disorders DBQ. Resolving all reasonable doubt in the Veteran’s favor, the Board finds that the criteria for service connection for an acquired psychiatric disorder have been met. The Board finds the Veteran’s reports that his mood changed in service, that he became more violent and had periods of sadness and mania in service and that his symptoms continued since service, to be competent and credible. The Board also finds that the statements of his aunt and sister that the Veteran changed during service and began experiencing symptoms of depression, withdrawal, anger and anxiety during service, and the Veteran’s symptoms worsened following service and have been continuous since service to competent and credible. The July 2019 private opinion establishes that the Veteran’s psychiatric disorder, to include bipolar disorder and anxiety disorder is related to service. The July 2019 opinion is competent, credible and probative, and coupled with the other medical evidence of record including the service records, VA and private treatment records, SSA records and lay evidence, supports a conclusion that service connection for an acquired psychiatric disorder is warranted. There is no contrary medical opinion of record. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. Thus, resolving all reasonable doubt in favor of the Veteran and based on the medical and lay evidence of record, the Board finds that evidence of record supports a finding that service connection for an acquired psychiatric disorder, to include bipolar disorder with anxiety and depression is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. 9. Entitlement to service connection for obstructive sleep apnea The Veteran seeks service connection for his obstructive sleep apnea, which he asserts is due to his psychiatric disorder. Service connection may be granted for a disability proximately due to or the result of a service-connected disability and where aggravation of a nonservice-connected disorder is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 446-449 (1995) (en banc). The Board has carefully reviewed the evidence of record and finds that the criteria for service connection for obstructive sleep apnea on the basis of secondary service connection have been met. As noted, the Veteran has been granted service connection for an acquired psychiatric disorder, to include bipolar disorder with anxiety and depression. Service treatment records are silent as to any complaints, treatment or clinical diagnosis of obstructive sleep apnea. The Veteran underwent a sleep study in July 2018, which reflected a diagnosis of severe positional obstructive sleep apnea. A July 2019 sleep apnea disability benefits questionnaire from a private examiner reflects a diagnosis of obstructive sleep apnea. The examiner noted that the Veteran was diagnosed with OSA and prescribed a CPAP following a sleep study in July 2018. The Veteran reported that he did not like the feel of his CPAP mask on his face because it caused him to feel anxious and to have panic attacks and caused him to remove his mask prematurely in the middle of the night. The Veteran’s inability to use the CPAP as prescribed caused him to be excessively sleepy during the day and required him to have a nap, which further aggravated his psychiatric symptoms, making them worse. The examiner opined that the Veteran’s bipolar disorder had aided in the development of and permanently aggravated his obstructive sleep apnea. The examiner opined that it was as likely as not that the Veteran’s bipolar disorder aided in the development of and permanently aggravated his OSA. The examiner noted that research had shown that psychiatric disorders are commonly associated with OSA; and patients with bipolar were more than twice as likely to develop sleep apnea than patients without bipolar. The examiner also noted that obesity was one factor which contributed to OSA and was a result of the Veteran’s bipolar disorder. Resolving all reasonable doubt in the Veteran’s favor, and with consideration of the objective medical evidence as well as the subjective lay evidence, the Board finds that the criteria for service connection for obstructive sleep apnea on the basis of secondary service connection have been met. The July 2019 private opinion establishes that the Veteran’s service-connected psychiatric disorder aggravated the Veteran’s obstructive sleep apnea. The July 2019 opinion is competent, credible and probative, and coupled with the other medical evidence of record including the service records, VA and private treatment records, Social Security Administration records and lay evidence, supports a conclusion that service connection for obstructive sleep apnea is warranted. There is no contrary medical opinion of record. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. Thus, resolving all reasonable doubt in favor of the Veteran and based on the medical and lay evidence of record, the Board finds that evidence of record supports a finding that service connection for obstructive sleep apnea is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. 10. Entitlement to service connection for headaches The Veteran seeks service connection for headaches, which he asserts is related to his psychiatric disorder. The Board has carefully reviewed the evidence of record and finds that the criteria for service connection for headaches based on secondary service connection have been met. The Veteran does not assert, and the evidence does not demonstrate, that the Veteran’s headaches occurred during a period of qualifying service. A March 2013 VA treatment record reflects a diagnosis of generalized anxiety disorder, bipolar I disorder, recurrent moderate major depressive disorder, and alcohol abuse. The Veteran reported having headaches. An August 2013 SSA consultative psychiatric examination reflects a diagnosis of bipolar affective disorder, past chronic alcohol abuse, rule out chronic alcoholism, past chronic drug use (cocaine). The Veteran’s medical problems included headaches. The examiner noted that the Veteran was prescribed ibuprofen for his headaches. A September 2015 VA treatment record reflects a diagnosis of bipolar disorder, currently depressed, panic disorder. The Veteran had a current headache, which was the result of sleeping very little. A July 2018 sleep study indicated that the Veteran medical history included snoring, disturbed sleep and morning headache. A July 2019 private headache disability benefits questionnaire reflects a diagnosis of tension headaches. The examiner noted that the Veteran suffered from daily prostrating attacks of headache pain each week that were accompanied with occasional vomiting, light and sound sensitivity, disturbed concentration, sensory changes, blurred vision, and dizziness. The examiner opined that it was as likely as not that the Veteran’s bipolar disorder aided in the development of and permanently aggravated his tension headaches. The examiner noted that the Veteran reported that when his bipolar disorder was bothering him, he became stressed out, and this would bring on a headache or make an already existing headache worse. The examiner noted that medical research stated that patients with mental health conditions were more likely to develop headaches because pain and mood were regulated by the same part of the brain. The examiner noted that it was well-established that mental disorders both caused and aggravated headaches. Resolving all reasonable doubt in the Veteran’s favor, and with consideration of the objective medical evidence as well as the subjective lay evidence, the Board finds that the criteria for service connection for headaches based on secondary service connection have been met. The July 2019 private opinion establishes that the Veteran’s headaches are related to his service-connected psychiatric disorder. The July 2019 opinion is competent, credible and probative, and coupled with the other medical evidence of record including the service records, VA and private treatment records, Social Security Administration records and lay evidence, supports a conclusion that service connection for headaches is warranted. There is no contrary medical opinion of record. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. Thus, resolving all reasonable doubt in favor of the Veteran and based on the medical and lay evidence of record, the Board finds that evidence of record supports a finding that service connection for headaches is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Gilbert, supra. REASONS FOR REMAND Examinations VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service, and the record does not contain sufficient information to make a decision on the claims. 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The requirement that the evidence “indicates” that the Veteran’s disability “may” be associated with his service is a low threshold. Id. 1. Entitlement to service connection for arthritis is remanded. The Veteran seeks service connection for arthritis. The record on appeal shows diagnoses of possible bilateral hand arthritis, and of arthritis of the low back and hands. With respect to the hands, a November 2014 VA treatment record reflects a diagnosis of chronic bilateral hand pain, possibly osteoarthritis. The treatment provider noted that the Veteran had a history of significantly increased activity and lifting while in the military. See also March 2013 VA treatment record. With respect to the low back, a June 1985 service treatment record reflects that the Veteran complained of back pain for two hours. Post-service treatment records include a November 2014 VA treatment record, which reflects a diagnosis of possible osteoarthritis with a notation that the Veteran had a history of significantly increased activity and lifting while in the military and was currently obese. An April 2016 VA treatment record reflects a diagnosis of low back pain with degenerative joint disease. With respect to the knees, a November 2014 VA treatment record reflects a diagnosis of possible osteoarthritis. The treatment provider noted that the Veteran had a history of significantly increased activity and lifting while in the military and was currently obese. An April 2016 VA treatment record reflects a diagnosis of knee pain with degenerative joint disease. Thus, in light of the Veteran’s contentions and the record on appeal, a VA examination should be obtained to determine the probable etiology of the Veteran’s arthritis to include of the bilateral hands, low back, and bilateral knees. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon, supra. 2. Entitlement to service connection for ED is remanded. The Veteran seeks service connection for erectile dysfunction, which he asserts is related to service. A June 1985 and July 1985 service treatment records reflect a diagnosis of a possible venereal disease. Thus, in light of the Veteran’s contentions and the record on appeal, a VA examination should be obtained to determine the probable etiology of the Veteran’s erectile dysfunction, to include whether the Veteran’s erectile dysfunction is related to service or to his service-connected psychiatric disorder. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon, supra. 3. Entitlement to service connection for frostbite is remanded. The Veteran seeks service connection for frostbite, which he asserts is related to service. Service treatment records reflect that the Veteran reported a cold injury to both feet in January 1986. The Board finds that the issue of entitlement to service connection for frostbite is inextricably intertwined with his pending claim of entitlement to service connection for a right foot disability. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). As previously noted, the issue of entitlement to service connection for a right foot disability has been remanded by the Board in July 2019 for additional development, to include a VA examination and the issue will be the subject of another Board decision, if in order. Therefore, action on the issue of entitlement to service connection for frostbite is deferred pending additional development. The matters are REMANDED for the following action: 1. The AOJ should ensure that the Veteran’s complete service personnel records from his active duty service, ACDUTRA service, and INACDUTRA service, to include service in the United States Army and Army Reserve, to determine the specific dates of active duty service, ACDUTRA service, and INACDUTRA service, are of record. 2. Then, schedule the Veteran for a VA examination to ascertain the nature and etiology of the Veteran’s claimed arthritis to include of the bilateral hands, low back, and bilateral knees. All necessary tests should be conducted. The AOJ should ensure that the examiner has access to the Veteran’s claims file, including a copy of this remand. Following a review of the Veteran’s record, the examiner should address the following: (a.) Identify all joints that are affected by arthritis to include the bilateral hands, low back, and bilateral knees. (b.) With respect to each joint affected by arthritis to include the hands, low back, and knees, state whether it is at least as likely as not (50 percent or greater likelihood) that such disorder manifested during service, that arthritis was manifest to a compensable degree within one year of a period of active duty service, or that it is otherwise causally or etiologically related to a period of qualifying service. In rendering the opinions, the examiner should consider the statements of the Veteran regarding the symptoms of arthritis to be competent. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 3. Then, schedule the Veteran for a VA examination to ascertain the nature and etiology of the Veteran’s ED. All necessary tests should be conducted. The AOJ should ensure that the examiner has access to the Veteran’s claims file, including a copy of this remand. Following a review of the Veteran’s record, the examiner should address the following: (a.) whether it is at least as likely as not (50 percent or greater likelihood) that ED manifested during service or that it is otherwise causally or etiologically related to a period of qualifying service; (b.) whether it is at least as likely as not (50 percent or greater likelihood) that ED is proximately due to a service-connected disability to include the Veteran’s psychiatric disorder; (c.) whether it is at least as likely as not (50 percent or greater likelihood) that ED is aggravated (increase in severity beyond the natural progression of the disorder) by a service-connected disability to include the Veteran’s psychiatric disorder. In rendering the opinions, the examiner should consider the statements of the Veteran regarding the symptoms of his ED to be competent. (Continued on the next page)   The examiner should provide a complete rationale for all opinions expressed and conclusions reached. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Johnson The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.