Citation Nr: 20023074 Decision Date: 04/02/20 Archive Date: 04/02/20 DOCKET NO. 19-20 068 DATE: April 2, 2020 ORDER The reduction of the Veteran's disability rating for right carpal tunnel syndrome (CTS), from 30 percent to 10 percent disabling, effective September 1, 2017, was improper, and restoration of the 30 percent disability rating is granted, effective September 1, 2017. New and material evidence has been received to reopen the previously denied claim for service connection for vision problems, and to this extent only, the appeal is granted. New and material evidence has been received to reopen the previously denied claim for service connection for hypertension, and to this extent only, the appeal is granted. New and material evidence has been received to reopen the previously denied claim for service connection for chronic obstructive pulmonary disorder (COPD), and to this extent only, the appeal is granted. New and material evidence has been received to reopen the previously denied claim for service connection for bilateral shoulder disability, and to this extent only, the appeal is granted. Entitlement to service connection for obstructive sleep apnea (OSA) as secondary to service-connected scleroderma is granted. REMANDED Whether new and material evidence has been received to reopen a claim of entitlement to service connection for left CTS is remanded. Entitlement to service connection for vision problems, to include as secondary to service-connected scleroderma is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected scleroderma, is remanded. Entitlement to service connection for COPD, to include as secondary to service-connected scleroderma, is remanded. Entitlement to service connection for a bilateral shoulder disability, to include as secondary to service-connected scleroderma and right CTS, is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected scleroderma, is remanded. Entitlement to service connection for a musculoskeletal disability, to include as secondary to service-connected scleroderma, is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for a right foot disability, to include as secondary to service-connected scleroderma, is remanded. Entitlement to service connection for seasonal allergies is remanded. Entitlement to a rating in excess of 60 percent for systemic scleroderma is remanded. Entitlement to a rating in excess of 20 percent for hepatitis B with gastroesophageal reflux disease (GERD) is remanded. Entitlement to a rating in excess of 30 percent for right CTS is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance or housebound status is remanded. Entitlement to specially adapted housing is remanded. FINDINGS OF FACT 1. The evidence of record at the time of the June 2017 rating decision did not demonstrate sustained and material improvement in the Veteran's service-connected right CTS that would be maintained under the ordinary conditions of life. 2. The Veteran’s claim for service connection for vision problems was last denied in an April 2013 rating decision that was not timely appealed, nor was any new and material evidence submitted within the appeal period; that decision is final. 3. The Veteran’s claim for service connection for hypertension was last denied in an April 2013 rating decision that was not timely appealed, nor was any new and material evidence submitted within the appeal period; that decision is final. 4. The Veteran’s claim for service connection for COPD was last denied in a June 2014 rating decision that was not timely appealed, nor was any new and material evidence submitted within the appeal period; that decision is final. 5. The Veteran’s claim for service connection for a bilateral shoulder disability was last denied in a June 2014 rating decision that was not timely appealed, nor was any new and material evidence submitted within the appeal period; that decision is final. 6. The Veteran’s OSA is aggravated beyond its natural progression by her service-connected scleroderma. CONCLUSIONS OF LAW 1. The reduction of the disability rating for the Veteran's service-connected right CTS, from 30 to 10 percent was not in accordance with the applicable regulation, the criteria for restoration of the 30 percent rating have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.105, 3.344. 2. The criteria to reopen the claim for service connection for vision problems have been met. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. 3. The criteria to reopen the claim for service connection for hypertension have been met. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. 4. The criteria to reopen the claim for service connection for COPD have been met. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. 5. The criteria to reopen the claim for service connection for a bilateral shoulder disability have been met. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. 6. The criteria for service connection for OSA as secondary to scleroderma are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1984 to December 1995. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020 correspondences, the Veteran and her representative expressly raised the issue of entitlement to a TDIU. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. The record indicates that the Veteran has been unemployed during portions of the appeal period. Accordingly, the Board finds that a TDIU claim is part and parcel of the current appeal, and that issue has been added to the cover page. Rating Reduction 1. Whether the reduction for service-connected right CTS from 30 percent to 10 percent disabling effective September 1, 2017 was proper In this case, following a March 2012 VA examination, an April 2013 rating decision increased the Veteran's right CTS rating from 10 percent to 30 percent disabling, effective September 29, 2011. On November 30, 2015, the Veteran filed an increased rating claim for her right CTS. Following a February 2016 VA examination, a March 2016 rating decision proposed to reduce the Veteran’s right CTS rating from 30 percent to 10 percent disabling. In March 2016 letters, the Veteran was notified, at her address of record, of the proposed rating reduction. She was also informed of her rights to challenge the proposed reduction and her right to a hearing. The Veteran did not submit medical evidence regarding the severity of her right CTS or request a hearing. Following an April 2017 VA examination, a June 2017 rating decision reduced the disability rating for right CTS from 30 percent to 10 percent disabling, effective September 1, 2017. Accordingly, the Board finds that all notification requirements under 38 C.F.R. § 3.105(e) (2019) were met. Turning to the substantive requirements, VA cannot reduce a veteran's disability evaluation without first finding, inter alia, that that an improvement has actually occurred in the service-connected disability and it has improved to the point that he or she is now better able to function under the ordinary conditions of life and work. See Murphy v. Shinseki, 26 Vet. App. 510, 517 (2014); Brown v. Brown, 5 Vet. App. 413, 421 (1993). Care must be taken to ensure that a change in an examiner's evaluation reflects an actual change in the Veteran's condition, and not merely a difference in the thoroughness of the examination or in descriptive terms, when viewed in relation to the prior disability history. See 38 C.F.R. §§ 4.1, 4.2, 4.13 (2019); see also Brown, 5 Vet. App. at 420-22. VA has the burden of establishing that the disability has improved. The focus of the inquiry is on the evidence of record available at the time the reduction was effectuated, although post-reduction medical evidence may be considered for the limited purpose of determining whether the condition has demonstrated actual improvement. See Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). Where VA has reduced a veteran's rating without observing applicable laws and regulations, such rating is void ab initio and will be set aside as not in accordance with the law. Kitchens v. Brown, 7 Vet. App. 320, 325 (1995). Where a rating reduction was made without observance of law, the reduction must be vacated, and the prior rating restored. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Additionally, where the rating has been in effect for five or more years, VA benefits recipients are to be afforded greater protections, as set forth in 38 C.F.R. § 3.344(a) and (b) (2019). In the present case, the 30 percent disability rating for right CTS had been in effect for more than five years at the time of the reduction. See Brown v. Brown, 5 Vet. App. 413, 418 (1993) (finding that duration of rating is measured from effective date of actual reduction). Accordingly, the protections of 38 C.F.R. § 3.344(a) and (b) (2019) are applicable. Under 38 C.F.R. § 3.344(a) (2019) the entire record of examination and the medical-industrial history must be reviewed to ascertain whether the recent examination is full and complete, including all special examinations indicated as a result of general examination and the entire case history. Examinations which are less thorough than those on which payments were originally authorized or continued will not be used as a basis for reduction. Id. Ratings for diseases subject to temporary or episodic improvement will not be reduced based on any one examination, except in those instances where all the evidence of record clearly warrants the conclusion that sustained improvement has been demonstrated. Id. Moreover, where material improvement in the physical or mental condition is clearly reflected, the rating agency will consider whether the evidence makes it reasonably certain that the improvement will be maintained under the ordinary conditions of life. Id. If doubt remains, after according due consideration to all the evidence developed, the rating in effect will continue. 38 C.F.R. § 3.344(b). The Veteran's 30 percent disability rating for her right CTS was authorized and continued based on March 2012 and June 2014 VA examinations. At a March 2012 VA examination, the Veteran reported that she wore a brace intermittently and “shakes her hand to give relief” of her right CTS symptoms. The examiner indicated that the Veteran had moderate constant pain, severe intermittent pain, moderate paresthesias, and moderate numbness in her right upper extremity due to her right CTS. Upon testing, the Veteran was noted to have full muscle strength without any evidence of atrophy or trophic changes. Reflex and sensory testing was also within normal limits. The examiner opined that the Veteran had moderate incomplete paralysis of the right median nerve, which did not result in any functional impairment in the Veteran’s ability to work. At a June 2014 VA examination, the Veteran reported that she treated her right CTS with physical therapy, ointment, and massage. She denied using a brace or other assistive device. She reported that her current symptoms included intermittent swelling, a heavy sensation in her hand, and moderate throbbing pain. The examiner indicated that the Veteran had moderate constant pain, moderate intermittent pain, moderate paresthesias, and mild numbness in her right upper extremity due to her right CTS. Upon testing, the Veteran was noted to have full muscle strength without any evidence of muscle atrophy or trophic changes. Reflex and sensory testing was within normal limits. The examiner opined that the Veteran had mild incomplete paralysis of the median nerve. The examiner opined right CTS did not render her totally and permanently unable to secure and maintain substantially gainful employment with both physical and sedentary work. However, the examiner did not detail what, if any, functional limitations that Veteran experienced as a result of her right CTS. The February 2016 VA examination report, which was the basis of the proposed reduction, indicated that the Veteran reported that she wears night splints and had daily mild pain that worsened with prolonged activity and cloudy weather. She denied taking any medication for her CTS. The examiner indicated that the Veteran had mild constant pain, moderate intermittent pain, mild paresthesias, and mild numbness in her right upper extremity due to her right CTS. Upon testing, the Veteran was noted to have full muscle strength without any evidence of muscle atrophy or trophic changes. Sensory testing was within normal limits, but reflex testing indicated that the Veteran’s right biceps, triceps, and brachioradialis reflexes were hypoactive. The examiner opined that the Veteran had mild incomplete paralysis of the median nerve. The examiner indicated that the Veteran required regular use of a brace due to her CTS and opined that her right CTS would have interfere with prolonged lifting, carrying, and computer use. The April 2017 VA examination report, which was the basis of the June 2017 rating reduction, indicates that the Veteran reported that she had a “dead feeling,” numbness, tingling, and pain in her right hand especially when performing repetitive movements or driving. She noted that she had been prescribed a brace and three medications for her right CTS symptoms. The examiner indicated that the Veteran had no constant pain, mild intermittent pain, mild paresthesias, and mild numbness in her right upper extremity due to her right CTS. Upon testing, the Veteran had reduced muscle strength for wrist flexion, wrist extension, and grip. Specifically, her muscle strength was assessed as a 4/5, which equates to active movement against some resistance. The examiner indicated that there was no evidence of muscle atrophy or trophic changes. Sensory and reflex testing was within normal limits. The examiner opined that the Veteran had mild incomplete paralysis of the median nerve. The examiner confirmed that the Veteran required occasional use of a brace due to her CTS and opined that her right CTS resulted in functional limitations in the form of a decreased ability to grip items. A January 5, 2017 VA treatment record notes that the Veteran reported numbness in her right hand and was prescribed methotrexate and a wrist splint for her right CTS. Additionally, a May 21, 2019 VA record indicates that the Veteran reported that she was experiencing severe numbness in her right hand. After reviewing the evidence, the Board finds that the weight of the evidence is against a finding actual improvement in the Veteran's service-connected right CTS. While the February 2016 and April 2017 VA examinations reflected an improvement in the Veteran’s subjective sensory symptoms, they also indicated an increase in her objective symptoms. Specifically, the February 2016 examination indicated that the Veteran’s right upper extremity reflexes were hypoactive, and the April 2017 examination report indicated that she had reduced right wrist flexion, extension, right grip muscle strength. While the March 2012 and June 2014 VA examination reports noted more severe subjective sensory symptoms, they were silent for any objective symptoms associated with the Veteran’s right CTS. Additionally, the February 2016 and April 2017 examination reports indicated that the Veteran required medical treatment for her CTS. Specifically, use of a right wrist brace and medication. In contrast, the March 2012 and June 2014 VA examination reports for silent for any prescribed and ongoing medical treatment. Finally, the VA treatment records subsequent to the rating reduction indicate that the Veteran had reported increased sensory symptoms and continued to require medication and a brace for her right CTS. Accordingly, the Board finds that the record does not reflect actual improvement in function under the ordinary conditions of life and work. Therefore, the reduction from 30 percent to 10 percent for the Veteran's service-connected right CTS, effective from September 1, 2017, was improper. Accordingly, the 30 percent disability rating for a lumbar spine disability is restored, effective September 1, 2017. Petitions to Reopen Generally, 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 (2012). New evidence means existing evidence not previously submitted to VA. 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. 38 C.F.R. § 3.156(a) (2019). 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. Id. The Court has held that the law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). 2. Whether new and material evidence has been received to reopen the previously denied claim for service connection for vision problems Service connection for vision problems was initially denied in an April 2013 rating decision on the basis that the Veteran’s diagnosed eye conditions, hyperopia and astigmatism, were congenital or developmental defects that were not related to her military service. The Veteran did not submit a timely notice of disagreement or new and material evidence during the appeal period, and the decision became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.156(b), 20.302, 20.1103 (2019). The evidence received since the April 2013 rating decision includes evidence that is both new and material to the claim. See 38 C.F.R. § 3.156 (2019). For example, a February 6, 2017 VA treatment record indicates that the Veteran was diagnosed with dry eye syndrome. Additionally, in a June 4, 2014 record the Veteran asserted that her eye problems were related to her service-connected scleroderma. This evidence addresses the reason for the previous denials; that is, a disability for VA purposes and a possible nexus to service or a service-connected disability. The credibility of this evidence is presumed for purposes of reopening the claims. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the claim is reopened. 3. Whether new and material evidence has been received to reopen the previously denied claim for service connection for hypertension Service connection for hypertension was initially denied in an April 2013 rating decision on the basis that there was no evidence that the Veteran’s hypertension was related to service. The Veteran did not submit a timely notice of disagreement or new and material evidence during the appeal period, and the decision became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.156(b), 20.302, 20.1103 (2019). The evidence received since the April 2013 rating decision includes evidence that is both new and material to the claim. See 38 C.F.R. § 3.156 (2019). For example, an August 26, 2014 treatment record from Dr. Jakes suggests that the Veteran’s hypertension could be a complication of her scleroderma and a March 8, 2019 VA treatment record noted that the Veteran’s rheumatologist had changed her anti-hypertensive medication. This evidence addresses the reason for the previous denials; that is, a nexus to service or a service-connected disability and raises a reasonable possibility of substantiating the claim. The credibility of this evidence is presumed for purposes of reopening the claims. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the claim is reopened. 4. Whether new and material evidence has been received to reopen the previously denied claim for service connection for COPD Service connection for COPD was last denied in a June 2014 rating decision on the basis that there was no evidence that the Veteran’s COPD was related to service. The Veteran did not submit a timely notice of disagreement or new and material evidence during the appeal period, and the decision became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.156(b), 20.302, 20.1103 (2019). The evidence received since the June 2014 rating decision includes evidence that is both new and material to the claim. See 38 C.F.R. § 3.156 (2019). For example, an August 26, 2014 treatment record indicates that the Veteran had an undifferentiated connective tissue disease, with inter alia a cough and shortness of breath. Dr. Jakes further noted that the Veteran’s conglomeration of symptoms pointed towards crest syndrome. In a June 2017 addendum opinion, a VA examiner clarified that “systemic sclerosis is another name for scleroderma and is part of crest syndrome.” This evidence addresses the reason for the previous denials; that is, a possible nexus to service or a service-connected disability and raises a reasonable possibility of substantiating the claim. The credibility of this evidence is presumed for purposes of reopening the claims. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the claim is reopened. 5. Whether new and material evidence has been received to reopen the previously denied claim for service connection for a bilateral shoulder disability Service connection for bilateral shoulder pain was initially denied in a June 2014 rating decision on the basis that there was no evidence that the Veteran’s shoulder pain was related to service. The Veteran did not submit a timely notice of disagreement or new and material evidence during the appeal period, and the decision became final. 38 U.S.C. § 7105(c) (2012); 38 C.F.R. §§ 3.156(b), 20.302, 20.1103 (2019). In December 2016, the Veteran filed a claim for a bilateral shoulder disability. The RO did not re-characterize the claim as a petition to reopen and instead denied the claim on the merits in a June 2017 rating decision. Nevertheless, the Board is required to address the issue of new and material evidence in the first instance. The evidence received since the June 2014 rating decision includes evidence that is both new and material to the claim. See 38 C.F.R. § 3.156 (2019). For example, a June 2017 VA skin examination report indicated that the Veteran had systemic manifestations of her scleroderma in the form of unspecified joint pain. Likewise, a December 2019 statement from Dr. Blevins indicated that the Veteran had “significant joint pain from scleroderma.” This evidence addresses the reason for the previous denials; that is, a possible nexus to service or a service-connected disability and raises a reasonable possibility of substantiating the claim. The credibility of this evidence is presumed for purposes of reopening the claims. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the claim is reopened. Service Connection 6. Entitlement to service connection for obstructive sleep apnea, to include as secondary to service-connected scleroderma Service connection may be established for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2019). Further, a disability that is aggravated by a service-connected disability may be service connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2019); Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran asserts that her OSA is caused or aggravated by her service-connected scleroderma. A January 2018 treatment record from Dr. Richardson and a December 2019 disability benefits questionnaire (DBQ) from Dr. Blevins indicate that the Veteran is diagnosed with OSA. Additionally, she is service connected for scleroderma. Accordingly, the question is whether the Veteran’s OSA is caused or aggravated by her service-connected disability. The record contains only one competent opinion on this issue. Specifically, in a December 2019 DBQ and corresponding statement, Dr. Blevins opined that the Veteran’s OSA was aggravated by her service-connected scleroderma and the prescribed treatment for her scleroderma symptoms. Dr. Blevins stated that frequent awakenings, in the case of this Veteran, due to significant joint pain from scleroderma, lead to fragmented sleep. She explained that when sleep is fragmented, an individual is unable to proceed normally through sleep cycles, which results in less time spent in deep sleep and rapid eye movement (REM) sleep. She noted that a study comparing the effects of sleep deprivation and sleep fragmentation on upper airway collapsibility revealed that sleep fragmentation lead to a higher incidence of upper airway collapsibility, the hallmark of OSA, and therefore it contributes to the pathogenesis of OSA. In support of her opinion, Dr. Blevins provide an abstract of an article entitled “Effects of sleep deprivation and sleep fragmentation on upper airway collapsibility in normal subjects,” which states that “[s]leep-related breathing abnormalities were more frequent after sleep fragmentation.” Dr. Blevins than stated that based on a review of the claims file, an interview of the Veteran, and medical research, it was her opinion that it was as likely as not that the Veteran’s service-connected scleroderma significantly contributed to and aggravated her OSA. Upon review of the competent and probative evidence of record, the Board finds that the Veteran’s current OSA is secondary to her service-connected scleroderma. The record contains an uncontradicted positive nexus opinion that is supported by an adequate rationale. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for OSA as secondary to service-connected scleroderma is granted. 38 C.F.R. § 3.102 (2019). REASONS FOR REMAND 1. Whether new and material evidence has been received to reopen a claim of entitlement to service connection for left CTS is remanded. 2. Entitlement to service connection for vision problems, to include as secondary to service-connected scleroderma, is remanded. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected scleroderma, is remanded. 4. Entitlement to service connection for COPD, to include as secondary to service-connected scleroderma, is remanded. 5. Entitlement to service connection for a bilateral shoulder disability, to include as secondary to service-connected scleroderma and right CTS, is remanded. 6. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected scleroderma, is remanded. 7. Entitlement to service connection for a musculoskeletal disability, to include as secondary to service-connected scleroderma, is remanded. 8. Entitlement to service connection for headaches is remanded. 9. Entitlement to service connection for a right foot disability, to include as secondary to service-connected scleroderma, is remanded. 10. Entitlement to service connection for seasonal allergies is remanded. 11. Entitlement to a rating in excess of 60 percent for systemic scleroderma is remanded. 12. Entitlement to a rating in excess of 20 percent for hepatitis B with GERD is remanded. 13. Entitlement to a rating in excess of 30 percent for right CTS is remanded. 14. Entitlement to a TDIU is remanded. 15. Entitlement to SMC based on the need for aid and attendance or housebound status is remanded. 16. Entitlement to specially adapted housing is remanded. The evidence indicates there may be outstanding relevant VA treatment records. A May 8, 2019 VA treatment record indicates that the Veteran was to return for a follow up appointment in September 2019. VA treatment records subsequent to June 17, 2019 have not been associated with the claims file. On a January 2020 VA Form 21-8940, the Veteran reported receiving treatment at the Central Alabama VA Health Care system (CAVHCS) from 1997 to present and at the Birmingham VA Medical Center (VAMC) from 2015 to present. The earliest VA treatment records from the CAVHCS are from June 21, 2000 and the most contemporaneous records from the Birmingham VAMC are from March 21, 2016. Additionally, VA treatment records from December 15, 2010, August 5, 2011, August 6, 2014, August 7, 2014, August 29, 2014, October 24, 2014, April 17, 2015, July 23, 2015, January 27, 2016, November 15, 2016, February 26, 2018, April 23, 2018, May 30, 2018, March 6, 2019, April 30, 2019, and June 11, 2019 note that neurology records, non-VA pulmonary function tests, non-VA records from Montgomery Imaging Center from September 22, 2014, non-VA rheumatology records from March 30, 2015, May 12, 2016, August 3, 2016, and October 26, 2016, certification of employee’s serious medical condition form, non-VA physical therapy records, non-VA allergy records, and unidentified non-VA care records had been scanned into VistA Imaging. It does not appear that the referenced records have been associated with the claims file. A remand to obtain the outstanding records is required. The record indicates that there are outstanding private treatment records. VA treatment records from September 9, 2009, September 14, 2012, and March 8, 2019 indicate that the Veteran received private treatment from a chiropractor in Montgomery, the Birmingham Kirkland Clinic, and a non-VA primary care provider. Additionally, a January 2020 VA Form 21-8940 indicates that the Veteran received treatment from Dr. Jakes as recently as 2019. While some records from Dr. Jakes were submitted received in March 2017, the most recent records are dated in August 2014. On remand, reasonable efforts should be made to obtain the private treatment records. Having reopened the Veteran’s vision, hypertension, COPD, and bilateral shoulder claims, the Board finds that further medical clarification is required. Specifically, the Board cannot make a fully informed decision on the issues because no VA examiner has opined whether the Veteran’s claimed vision problems, hypertension, COPD, and bilateral shoulder pain are secondary to her service-connected scleroderma, whether her dry eye syndrome and bilateral shoulder pain are related to service, or whether her bilateral shoulder shoulder pain is aggravated by her service-connected right CTS. The Board notes that a VA opinion was obtained in April 2017 to address whether the Veteran’s bilateral shoulder disability was secondary to her service-connected right CTS. The examiner stated that the Veteran’s bilateral shoulder disability was not proximately due to or the result of the Veteran’s right CTS. Nevertheless, the examiner’s opinion did not address the aggravation prong of secondary service-connection. See Allen v. Brown, 7 Vet. App. 439, 449 (1995) (stating that “caused by” and “related to” do not address the aggravation aspect of secondary service connection). With respect to the Veteran’s claims for an acquired psychiatric disorder, a musculoskeletal disorder, and headaches, the Veteran has not been afforded VA examinations. VA treatment records from November 10, 2015 and August 21, 2017 note diagnoses of somatic symptom disorder and polyarthralgia. A January 10, 2018 treatment record from Dr. Richland notes that the Veteran has reported frequent severe headaches. On her September 1995 report of medical history at discharge, the Veteran endorsed swollen or painful joints and “[d]epression or excessive worry.” An October 23, 1987 service treatment record indicates that the Veteran reported headaches. Accordingly, the Board cannot make a fully informed decision on the issues because no VA examiner has opined whether the Veteran’s conditions are related to service. Additionally, in a January 2020 correspondence, the Veteran’s representative asserted that the Veteran’s mental health symptoms were related to her service-connected scleroderma and treatise evidence, received on February 24, 2012, indicates that scleroderma may cause bone and muscle problems such as joint pain, pain, stiffness, and swelling of the joints. Accordingly, secondary service connection should also be addressed on remand. While the Veteran was provided a VA foot examination in November 2017, the Board finds that further clarification is required. The examiner noted diagnoses of pes planus, hallux valgus, and arthritis and opined that the conditions were less likely than not related to service. In support of that finding, the examiner noted that the Veteran’s September 1984 report of medical examination at enlistment indicated a diagnosis of pes planus and there were no contemporaneous service treatment records establishing a pattern of chronic right foot pain. Nevertheless, the examiner’s rationale did not address or acknowledge the other foot diagnoses of record, including metatarsalgia, plantar fasciitis, or hallux rigidus, or the fact that the Veteran endorsed foot trouble on her September 1995 report of medical history at discharge. Accordingly, an addendum opinion is required. Additionally, treatise evidence, received on February 24, 2012, indicates that scleroderma may cause foot pain. Accordingly, secondary service connection should also be addressed on remand. While the Veteran was provided a VA sinus examination in November 2017, the Board finds that further clarification is required. The examiner opined that the Veteran’s allergic rhinitis was less likely than not related to service because her September 1984 “enlistment physical examination” indicates that the Veteran was noted to have a seasonal cough and seasonal hay fever upon entry to the military. Therefore, it would seem the Veteran’s claimed allergies extended prior to enlistment and are not related to military service. While the Veteran reported a history of cough and hay fever on her September 1984 report of medical history (Form 93) at induction, the corresponding report of medical examination (Form 88) noted that clinical evaluation of the Veteran’s sinuses were normal. As such, the Veteran’s seasonal hay fever was not “noted” at induction. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304(b) (2019). Rebutting the presumption of soundness, requires clear and unmistakable evidence that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. 38 C.F.R. § 3.304(b) (2018); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Thus, the examiner applied the incorrect legal standard in opining that the Veteran's hay fever pre-existed service. Accordingly, an addendum opinion is warranted. Regarding the Veteran’s right CTS, the Veteran’s last VA peripheral nerve examination was in April 2017. At that time, she was noted to have mild numbness in her right upper extremity. A May 21, 2019 VA record notes the Veteran reported severe numbness in her right hand. Accordingly, she should be provided an opportunity to report for a VA examination to ascertain the current severity and manifestations of her right CTS. Finally, as noted above, the issue of TDIU has been raised. Specifically, the record indicates that the Veteran has been unemployed or employed only part-time during portions of the period on appeal. Moreover, her representative expressly raised the issue of entitlement to a TDIU. Thus, the Board finds that the issue of entitlement to a TDIU is part and parcel of the Veteran's increased rating claims. To date, this issue has not yet been fully developed or adjudicated by the AOJ. Accordingly, it is remanded for initial development and adjudication, to include obtaining information regarding the Veteran’s self-employment and her part-time employment as an office clerk, obtaining updated records from the Office of Personnel Management (OPM) regarding her medical retirement re-assessment in 2015, and obtaining records from the Alabama Department of Rehabilitation Services. The Board has not overlooked the Dr/ Blevins’ December 2019 opinion that the Veteran is unemployable. Nevertheless, as that opinion did not address or acknowledge the Veteran’s employment from June 2013 through January 2014 or August 2018 through November 2018, further clarification is required. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated her for her claimed disabilities, including her chiropractor in Montgomery, the Birmingham Kirkland Clinic, her non-VA primary care provider, and Dr. Jakes. After securing any necessary releases, the AOJ should request any relevant records identified. In addition, obtain updated VA treatment records dated since June 17, 2019, all treatment records from the CAVHCS dated prior to June 21, 2000, all treatment records from the Birmingham VAMC dated since March 21, 2016, as well as the VistA Imaging records referenced in the December 15, 2010, August 5, 2011, August 6, 2014, August 7, 2014, August 29, 2014, October 24, 2014, April 17, 2015, July 23, 2015, January 27, 2016, November 15, 2016, February 26, 2018, April 23, 2018, May 30, 2018, March 6, 2019, April 30, 2019, and June 11, 2019 VA record entries. If any requested records are unavailable, the Veteran should be notified of such. 2. Provide the Veteran and her representative notice pursuant to the Veterans Claims Assistance Act (VCAA) as to the issue of entitlement to a TDIU. Additionally, ask her to fully complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, to include any full-time employment, part-time employment, or volunteer activities. 3. Ask the Veteran to provide financial information, such as income tax return forms that include her net and gross profits, for her period of self-employment. 4. Obtain all outstanding records of vocational rehabilitation services or treatment from the Alabama Department of Rehabilitation Services and associate such records with the claims file. If the records are not available, the claims file should be annotated to reflect such, and the Veteran notified of such. 5. Obtain all OPM records regarding to the Veteran's medical retirement, to include her re-assessment in 2015. All records obtained should be associated with the claims file. If the records are not available, the claims file should be annotated to reflect such, and the Veteran notified of such. 6. After records development is completed to the extent possible, the Veteran should be afforded a VA eye examination to determine the nature of any eye disability and to obtain an opinion as to whether such is possibly related to service or a service-connected disability. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any current disability of the eye arose during service or is otherwise related to service, to include the Veteran’s assertions regarding excessive night vision driving. (b.) Whether it is at least as likely as not (50 percent probability or greater) that any eye disability was caused by the service-connected scleroderma? (c.) If not caused by the service-connected scleroderma, is it at least as likely as not that any eye disability is worsened beyond natural progression (aggravated) by her service-connected scleroderma? If the examiner finds that an eye disability was aggravated by her service-connected scleroderma, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the eye disability. A complete rationale should be provided for all opinions and conclusions expressed. 7. After records development is completed to the extent possible, the Veteran should be afforded a VA examination to determine the nature of her hypertension and to obtain an opinion as to whether such is possibly related to a service-connected disability. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that hypertension was caused by the service-connected scleroderma? (b.) If not caused by the service-connected scleroderma, is it at least as likely as not that the Veteran's hypertension is worsened beyond natural progression (aggravated) by her service-connected scleroderma? If the examiner finds that the Veteran's hypertension was aggravated by her service-connected scleroderma, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the hypertension. In rendering the above requested opinions, the examiner should address the treatise evidence received on February 24, 2012 indicating that scleroderma can cause severe inflammation of small blood vessels. A complete rationale should be provided for all opinions and conclusions expressed. 8. After records development is completed to the extent possible, the Veteran should be afforded a VA examination to determine the nature of any respiratory disorder and to obtain an opinion as to whether such is possibly related to a service-connected disability. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any respiratory disorder was caused by the service-connected scleroderma? (b.) If not caused by the service-connected scleroderma, is it at least as likely as not that any respiratory disorder is worsened beyond natural progression (aggravated) by her service-connected scleroderma? If the examiner finds that a respiratory disorder was aggravated by her service-connected scleroderma, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the respiratory disorder. In rendering the above requested opinions, the examiner should address the treatise evidence received on February 24, 2012 indicating that scleroderma can cause scarring in the lungs and breathing problems. A complete rationale should be provided for all opinions and conclusions expressed. 9. After records development is completed to the extent possible, the Veteran should be afforded a VA examination to determine the nature of any bilateral shoulder disability and to obtain an opinion as to whether such is possibly related to service or a service-connected disability. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any current disability of the right or left shoulder arose during service or is otherwise related to service, to include the Veteran’s September 1995 endorsement of swollen or painful joints. (b.) Whether it is at least as likely as not (50 percent probability or greater) that any right or left shoulder disability was caused by the service-connected scleroderma and/or right CTS? (c.) If not caused by the service-connected scleroderma and/or right CTS, is it at least as likely as not that any right or left shoulder disability is worsened beyond natural progression (aggravated) by her service-connected scleroderma and/or right CTS? If the examiner any right or left shoulder disability was aggravated by her service-connected scleroderma and/or right CTS, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the shoulder disability. In rendering the above requested opinions, the examiner should address the treatise evidence received on February 24, 2012 indicating that scleroderma can cause joint pain, stiffness, and swelling, the February 2012 VA peripheral nerve examination noting generalized joint pain associated with systemic scleroderma, and the June 2017 VA skin examination noting unspecified joint pain as a systemic manifestation of scleroderma. A complete rationale should be provided for all opinions and conclusions expressed. 10. After records development is completed to the extent possible, the Veteran should be afforded a VA examination to determine the nature of any acquired psychiatric disorder and to obtain an opinion as to whether such is possibly related to service or a service-connected disability. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any acquired psychiatric disorder arose during service or is otherwise related to service, to include the Veteran’s September 1995 endorsement of depression or excessive worry. (b.) Whether it is at least as likely as not (50 percent probability or greater) that any acquired psychiatric disorder was caused by the Veteran’s service-connected disabilities (scleroderma, hepatitis B, right CTS, GERD, and OSA)? (c.) If not caused by the Veteran’s service-connected disabilities, is it at least as likely as not that any acquired psychiatric disorder is worsened beyond natural progression (aggravated) by her service-connected disabilities? If the examiner finds that any acquired psychiatric disorder was aggravated by her service-connected disabilities the examiner should attempt to quantify the level of aggravation beyond the baseline level of the acquired psychiatric disorder. In so opining, the examiner should address the VA records indicating that the Veteran reported mental health symptoms, including depression and anxiety, related to her pain and medical conditions. See e.g., June 14, 2011, June 11, 2014, October 13, 2015, and November 10, 2015 VA treatment record. A complete rationale should be provided for all opinions and conclusions expressed. 11. After records development is completed to the extent possible, the Veteran should be afforded a VA examination to determine the nature of any musculoskeletal disorder and to obtain an opinion as to whether such is possibly related to service or a service-connected disability. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to: (a.) Whether it is at least as likely as not (50 percent probability or greater) that a musculoskeletal disability arose during service or is otherwise related to service, to include the Veteran’s September 1995 endorsement of swollen or painful joints. (b.) Whether it is at least as likely as not (50 percent probability or greater) that a musculoskeletal disability was caused by the service-connected scleroderma? (c.) If not caused by the service-connected scleroderma, is it at least as likely as not that a musculoskeletal disability is worsened beyond natural progression (aggravated) by her service-connected scleroderma? If the examiner finds that a musculoskeletal disability was aggravated by her service-connected scleroderma, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the musculoskeletal disability. In rendering the above requested opinions, the examiner should address the treatise evidence received on February 24, 2012 indicating that scleroderma can cause joint pain, stiffness, and swelling, the February 2012 VA peripheral nerve examination noting generalized joint pain associated with systemic scleroderma, and the June 2017 VA skin examination noting unspecified joint pain as a systemic manifestation of scleroderma. A complete rationale should be provided for all opinions and conclusions expressed. 12. After records development is completed to the extent possible, the Veteran should be afforded a VA examination to determine the nature of a headache disability and to obtain an opinion as to whether such is possibly related to service. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that a current headache disability arose during service or is otherwise related to service, including the October 23, 1987 service treatment record noting that the Veteran experienced headaches “during week she is off pill.” A complete rationale should be provided for all opinions and conclusions expressed. 13. After records development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's right foot claim. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine: (a.) For the Veteran’s pre-existing pes planus, state whether the condition underwent a permanent worsening during the Veteran's service. Please explain why or why not. (b.) For any foot disability that did not pre-exist service, state whether it is at least as likely as not (50 percent probability or greater) that it arose during service or is otherwise related to service, to include the Veteran’s September 1995 endorsement of swollen or painful joints and foot trouble. (c.) For any foot disability present during the pendency of the appeal, state whether it is at least as likely as not (50 percent probability or greater) that it was caused by the service-connected scleroderma? (d.) If not caused by the service-connected scleroderma, is it at least as likely as not that it is worsened beyond natural progression (aggravated) by her service-connected scleroderma? If the examiner finds that any foot disability was aggravated by her service-connected scleroderma, the examiner should attempt to quantify the level of aggravation beyond the baseline level of the foot disability. In rendering the above requested opinions, the examiner should address the treatise evidence received on February 24, 2012 indicating that scleroderma can cause joint pain, stiffness, swelling in the joints, and numbness and pain in the feet, the February 2012 VA peripheral nerve examination noting generalized joint pain associated with systemic scleroderma, and the June 2017 VA skin examination noting unspecified joint pain as a systemic manifestation of scleroderma. A complete rationale should be provided for all opinions and conclusions expressed. 14. After records development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's seasonal allergies claim. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine: (a.) Whether the Veteran’s allergic rhinitis undebatably existed prior to active service. Please explain why or why not. (b.) If the Veteran’s allergic rhinitis preexisted service, did the condition undergo a permanent worsening during the Veteran’s service? Please explain why or why not. (c.) If the preexisting condition was permanently worsened during service, was that worsening undebatably due to the natural progress of the disability? Please explain why or why not. (d.) If the Veteran’s allergic rhinitis did not preexist service, state whether it is at least as likely as not (50 percent probability or greater) that her allergic rhinitis arose during service or is otherwise related to service. A rationale for all opinions expressed should be provided. 15. After records development is completed, schedule the Veteran for a VA peripheral nerve examination to determine the current severity of her service-connected right carpal tunnel syndrome (CTS). The claims file should be reviewed by the examiner. All necessary tests should be performed, and the results reported. All symptomatology associated with the Veteran’s right CTS should be reported. 16. If the claims remain denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Anderson 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.