Citation Nr: 20043715 Decision Date: 06/29/20 Archive Date: 06/29/20 DOCKET NO. 13-36 168 DATE: June 29, 2020 ORDER Service connection for headaches is granted. Service connection for rectal bleeding and associated pain (claimed as hemorrhoids) is granted. A disability rating in excess of 20 percent for a left knee disability from February 2, 2015 is denied. REMANDED Service connection for sleep apnea is remanded. Service connection for a respiratory disability to include chronic obstructive pulmonary disease (COPD), restrictive lung disease (RLD), and tuberculosis is remanded. FINDINGS OF FACT 1. The Veteran has manifested unexplained headaches to a compensable degree prior to December 31, 2021 after serving in the South West Asia Theatre of Operations after August 2, 1990. 2. The Veteran has manifested unexplained rectal bleeding and associated pain to a compensable degree prior to December 31, 2021 after serving in the South West Asia Theatre of Operations after August 2, 1990. 3. From to February 2, 2015, the Veteran did not manifest ankylosis, recurrent subluxation, lateral instability, dislocated semilunar cartilage, removal of semilunar cartilage, extension limited to 20 degrees or more, a flexion limited to 15 degrees or less, an extension limited to 10 degrees or more and a flexion limited to 45 degrees or less, impairment of the tibia or fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.304; 3.307; 3.309; 3.310; 3.317. 2. The criteria for service connection for rectal bleeding claimed has hemorrhoids have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.304; 3.307; 3.309; 3.310; 3.317. 3. The criteria for a disability in excess of 20 percent for left knee disability from to February 2, 2015 have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71A, Diagnostic Codes 5003, 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from March 1985 to August 2000. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a December 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This appeal is being adjudicated under the legacy appellate framework. The Veteran testified at a personal hearing before the Board in June 2018, and a transcript of the hearing is of record. These matters were previously before the Board, and, in February 2019, the Board remanded these matters for further development. Further development in substantial compliance with the Board’s previous remand instructions has been completed. The Board notes that, in February 2019, the Board also remanded the issue of service connection for a back disability. In April 2020 however, the Veteran was granted service connection for a back disability. As this is considered a full grant of the Veteran’s requested prayer of relief, the Board shall not address this issue any further. The Board notes that in April 2019 the Veteran’s representative contacted VA in order to inform VA that VA was not using the Veteran’s representative’s correct address as well as to provide VA with the correct address. The Board further notes that, under certain circumstances, this might require postponing disposition of the case at bar until it could be verified that the Veteran’s representative was appraised of the full contents of the claims file and did not have further evidence or argument to submit. In this case however, the record is silent after April 2019 for any indication that the error complained of had not been cured. Moreover, the Veteran’s representative has had ample opportunity (over a year in fact) to raise any further objections or request any extensions. Finally, this case has been advanced on the docket specifically due to the fact that the Veteran and the Veteran’s representative desire an expedited disposition of the case at bar. Therefore, the Board shall dispose of the case at bar without any further inquiry into the April 2019 statement at this time. Service Connection In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. “Service connection” basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Furthermore, service connection can be established through application of statutory presumptions. Service connection may be granted on a presumptive basis for chronic diseases that manifest to a compensable degree within a year of separation from service, or when there is continuity of symptomology since separation from service. 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted on a presumptive basis for unexplained diseases associated with service in the South West Asia Theatre of Operations Service connection that manifest to a compensable degree on or before December 31, 2016. 38 C.F.R. § 3.317. Service connection may be granted on a secondary basis for diseases that are proximately due to or aggravated by a previously service-connected disability. Service connection may also be granted on a secondary basis for Parkinsonism, dementia, depression, and diseases of hormone deficiency may be granted as secondary to traumatic brain injury (TBI). 38 C.F.R. § 3.310(d). Finally, diseases may be granted on a secondary basis when obesity serves as an intermediate step between a previously service-connected disability and a disability claimed as secondary to a previously service-connected disability. See VA Office of General Counsel Precedential Opinion (January 6, 2017) (hereinafter VAOPGCPREC 1-2017). 1. Service connection for headaches is granted. At issue is whether the Veteran is entitled to service connection for headaches. The weight of the evidence indicates that the Veteran is entitled to service connection. The Veteran is entitled to service connection on a presumptive basis for service in the South West Theatre of Operations. The Veteran’s DD-214 indicates that the Veteran served in the South West Asia Theatre of Operations from August 14, 1990 to April 1, 1991. The Veteran testified at a personal hearing before the Board in June 2018 that he manifested headaches severe enough to require him to call in sick to work one to two times per week. See Transcript. The Board finds this testimony sufficient to demonstrate that the Veteran manifested headaches severe enough to be considered characteristic of prostrating attacks at least once every two months prior to December 31, 2021. See Webster II New College Dictionary 889 (3rd ed. 2001) (defining prostrating as “physically or emotionally exhausted”). Such headaches would warrant at least a minimally compensable disability rating. 38 C.F.R. § 4.124A, Diagnostic Code 8100. Moreover, the record is silent for a medical explanation for the Veteran’s headaches, and all reasonable steps to rule out an explanation of the headaches have been made. As such, the weight of the evidence indicates that the Veteran, after serving in the South West Asia Theatre of Operations after April 1, 1991, manifested headaches to a compensable degree prior to December 31, 2021, and, despite an exhaustion of diagnostic procedures, his headaches remain unexplained. 38 C.F.R. § 3.317. The Board is aware that a February 2020 VA examination notes a “diagnosis” of unspecified headache. This diagnosis is used only when, based on all available information, a physician can only indicate that the Veteran has a headache without any further classification or description. See International Classification of Headache Disorders 3rd. Ed. (ICHD-3) available at https://ichd-3.org/14-other-headache-disorders/14-2-headache-unspecified/ (last visited June 18, 2020). As such, the Board does not find the examiner’s “diagnosis” to be anything more than mere repetition of the Veteran’s reports that his head hurts and cannot be considered an explanation of the Veteran’s symptoms. Moreover, the Board finds the examiner’s use of unspecified headaches sufficient to demonstrate that the Veteran has undergone all necessary procedures to rule out a more definitive explanation. The interpretation that the Veteran’s headaches cannot be considered an explanation for the purposes of presumptive service connection is also consistent with the regulatory language governing presumptive service connection based on service in the South West Asia Theatre of Operations (section 3.317) which permits service connection for “diagnosed” disabilities that are characterized by unexplained symptoms. 38 C.F.R. § 3.317. The regulatory language gives examples of such “diagnosed” disabilities. On such example in section 3.317 is fibromyalgia; which, for VA compensation purposes, is essentially unexplained chronic pain. Stankevich v. Nicholson, 19 Vet. App. 470 (2006). Moreover, the use of the word “such as” in section 3.317 indicates that the list of examples is illustrative rather than exhaustive. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (holding that the use of the word “such as” in the General Formula for Rating Mental Disorders renders the listed symptoms as illustrative of varying levels of occupational and social impairment rather than comprehensive list of all examples of occupational and social impairment). The Board is cognizant that the February 2020 VA examination opined that the Veteran’s headaches were not severe enough to be considered consistent with prostrating attacks. The Board is not a medical body and may not make independent medical findings; rather it must base its findings from competent sources. Colvin v. Derwinski, 1 Vet. App. 171 (1991). Nevertheless, “prostrating attacks” is a legal term derived from the schedular rating criteria outlined in the Code of Federal Regulations. 38 C.F.R. § 4.124A, Diagnostic Code 8100. Neither the rating schedule nor the courts have defined prostrating attacks, and, consequently, the Board, as discussed above, has adopted the common definition of “physically or emotionally exhausted.” See Webster II New College Dictionary 889 (3rd ed. 2001). As such, the VA examiner’s characterization of the Veteran’s headaches, though probative, is not dispositive. Moreover, the Veteran is competent to describe the severity of his headaches; Jandreau v. Nicholson, 492 F.3d 1372 (2007); and, as discussed above, the Board finds to Veteran’s testimony credible enough to find that the Veteran’s headaches are severe enough to be considered prostrating. The Board is also cognizant that the Veteran alleged during a personal hearing before the Board in June 2018 that he manifested headaches during a period of service after head trauma sustained after parachute jumps (suggesting the Veteran sustained some sort of TBI) and continued to manifest headaches ever since; see Transcript; and that the February 2020 VA examination indicated that these headaches were actually transitory symptoms of dehydration due to an infection. Nevertheless, this does not disturb the Board’s finding that there is no medical explanation for the Veteran’s current headaches, because, by the February 2020 VA examiner’s own determination, the dehydration headaches during service are unrelated to the Veteran’s current headaches. Moreover, the Board’s determination that the Veteran meets the criteria for service connection on a presumptive basis based on service in the South West Asia Theatre of Operations renders any alternative theory of service connection moot including: direct service connection 38 C.F.R. § 3.304; presumptive service connection for a chronic condition 38 C.F.R. §§ 3.307, 3.309; or service connection on a secondary basis; 38 C.F.R. § 3.310; to include as secondary to a TBI. 38 C.F.R. § 3.310(d). Here, the weight of the probative evidence of record indicates that the Veteran has manifested unexplained headaches to a compensable degree prior to December 31, 2021 after serving in the South West Asia Theatre of Operations after August 2, 1990. Therefore, the evidence in this case is evenly balanced enough so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to service connection for headaches is granted. 2. Service connection for rectal bleeding and associated pain claimed as hemorrhoids is granted. At issue is whether the Veteran is entitled to service connection for rectal bleeding and associated pain (originally claimed as hemorrhoids). The weight of the evidence indicates that the Veteran is entitled to service connection. The Veteran testified at a personal hearing before the Board in June 2018 that he first began to manifest blood in his stool during a period of service, and that this led to a diagnosis of hemorrhoids shortly after separating from service that this was treated with suppositories and colonoscopies. See Transcript. The Veteran underwent a VA examination in December 2019. During the examination the Veteran reported that, beginning in 1995, the Veteran began to manifest blood in his stool that was accompanied by pain and burning, and, that, at the time of the examination, the Veteran continued to manifest bleeding and pain while sitting with flare-ups severe enough to limit the Veteran’s ability to stand or sit. The examiner indicated that there was no diagnosis for the Veteran’s disability, and that the Veteran’s previously diagnosed hemorrhoids had resolved. The weight of the evidence indicates that the Veteran is entitled to service connection for rectal bleeding (which was initially claimed as hemorrhoids) due to service in the South West Asia Theatre of Operations. As previously noted, the Veteran’s DD-214 indicates that the Veteran served in the South West Asia Theatre of Operations from August 14, 1990 to April 1, 1991. The Veteran has provided competent and credible lay reports that he is manifesting gastrointestinal symptoms (in this case rectal bleeding) prior to prior to December 31, 2021 that, as discussed below in further detail, the Board is satisfied is sufficiently severe to be considered minimally compensable. Although initially explained by a diagnosis of hemorrhoids, a December 2019 VA examination indicates that the Veteran’s symptoms have persisted in spite of the fact that the Veteran’s hemorrhoids have resolved. Finally, the record is silent for a medical explanation for the Veteran’s current rectal bleeding and associated pain, and all reasonable steps to rule out an explanation of the Veteran’s rectal bleeding have been made. 38 C.F.R. § 3.317 The Board notes that the Veteran’s initial claim for a disability was for hemorrhoids, and a current disability or a manifestation during the pendency of the appeal is the cornerstone for a claim for service connection; Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); and that – all things being equal – a determination that the Veteran did not actually have the disability being claimed during the pendency of the appeal would typically lead to the denial the Veteran’s claim. Nevertheless, the Board finds that unexplained rectal bleeding and associated pain is an alternative explanation, or lack thereof, for the symptomology alleged in a claim for hemorrhoids, and, as such, unexplained rectal bleeding and associated pain are within the scope of the Veteran’s claim for service connection for hemorrhoids. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board notes that the criteria, for service connection on a presumptive basis for service in the South West Asia Theatre of Operations, require that the claimed disability manifest to a minimally compensable degree. 38 C.F.R. § 3.317. The Board further notes that – although the Veteran is being granted service connection for unexplained rectal bleeding and associated pain instead of hemorrhoids – the rating criteria for hemorrhoids would normally be a prime candidate for rating the Veteran’s disability by analogy; 38 C.F.R. § 4.20; and that the rating criteria for hemorrhoids does not assign compensable disability ratings for mild to moderate hemorrhoids that do not manifest secondary anemia or irreducible large or thrombotic tissue. 38 C.F.R. § 4.114, Diagnostic Code 7336. Nevertheless, pain alone may be considered a compensable disability for VA compensation purposes when it is severe enough to impact the Veteran’s ability to work. Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). A VA examiner has noted that, during flare-ups, the Veteran’s unexplained rectal bleeding is so painful that it prevents the Veteran from either sitting or standing. The Board finds that this is sufficiently painful that it would warrant the assignment of a disability rating based on the pain alone even if other symptoms associated with the Veteran’s unexplained rectal bleeding would not otherwise warrant a compensable disability rating. The intention of the rating schedule is to consider painful motion as productive of at least a minimally compensable disability rating. 38 C.F.R. § 4.59. True, section 4.59 is more often than not applied to musculoskeletal disabilities rather than unexplained rectal bleeding and associated pain. That being said in light the unexplained nature of the Veteran’s symptomology, the ability of the rating schedule to rate unidentified disabilities by analogy, the recent common law instructing VA to grant service connection for pain alone, and the fact musculoskeletal disabilities are some of the most common disabilities that are compensated based on pain alone, the Board finds that section 4.59 is not only an instructive guide, but perhaps the only guide, in how to interpret the rating schedule in light of the Veteran’s unique symptomology. As such, the Veteran’s rectal bleeding and associated pain is at least productive, but not necessarily more productive, of a minimally compensable disability rating. Here, the weight of the probative evidence of record indicates that the Veteran has manifested unexplained rectal bleeding and associated pain to a compensable degree prior to December 31, 2021 after serving in the South West Asia Theatre of Operations after August 2, 1990. Therefore, the evidence in this case is evenly balanced enough so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to service connection for unexplained rectal bleeding and associated pain (claimed as hemorrhoids) is granted. 3. A disability rating in excess of 20 percent from February 2, 2015 for a left knee disability is denied. At issue is whether the Veteran is entitled to increased or additional disability ratings for the left knee from February 2, 2015. The weight of the evidence indicates that the Veteran is not entitled to an increased disability rating. The Veteran first filed for service connection for a left knee disability in August 2005, and, in May 2006, the RO denied service connection. The decision became final after the Veteran failed to file a notice of disagreement (NOD) or additional evidence within one year after notification of the decision. The Veteran filed a claim to reopen his previously denied claim in December 2009, and, in December 2011, the RO granted the Veteran’s claim and assigned a disability rating of 10 percent effective the date the claim to reopen was received. The Veteran appealed his initial disability rating. During the pendency of the appeal, the Veteran was assigned a disability rating of 20 percent effective February 2, 2015. In February 2019, the Board disposed of the Veteran’s increased rating claim prior to February 2, 2015. The Veteran’s increased rating claim from February 2, 2015 is ready for disposition. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Disability ratings for knee disabilities are assigned pursuant to Diagnostic Codes 5003, 5256-5263. 38 C.F.R. § 4.71A, Diagnostic Codes 5003, 5256-5263. Diagnostic Codes 5256 (ankylosis), 5257 (recurrent subluxation or lateral instability), 5258 (dislocated semilunar cartilage), 5259 (removal of semilunar cartilage), 5262 (impairment of the tibia or fibula), and 5263 (genu recurvatum) are not raised by the record, because the Veteran did not manifest ankylosis, recurrent subluxation, lateral instability, dislocated semilunar cartilage, removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum of the left knee did not manifest during the pendency of the appeal. Diagnostic Code 5003 is not raised by the record either, because the maximum disability rating available under Diagnostic Code 5003 is 20 percent based on the arthritis of multiple joints; and the Veteran has already been assigned a combined disability rating of 20 percent for arthritis in multiple joints throughout the period on appeal. See April 2020 Rating Decision Code Sheet. 38 C.F.R. § 4.71A, Diagnostic Codes 5003, 5256-5259, 5262-5263. Under Diagnostic Code 5260, a disability rating of 10 percent is assigned when flexion is limited to 45 degrees, and a disability rating of 20 percent is assigned when flexion is limited to 30 degrees. A disability rating of 30 percent is assigned when flexion is limited to 15 percent. 38 C.F.R. § 4.71A, Diagnostic Code 5260. Under Diagnostic Code 5261, a disability rating of 10 percent is assigned when extension is limited to 10 degrees, and a disability rating of 20 percent is assigned when extension is limited to 15 degrees. A disability rating of 30 percent is assigned when extension is limited to 20 degrees, and a disability rating of 40 percent is assigned when extension is limited to 30 degrees. A disability rating of 50 percent is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71A, Diagnostic Code 5261. The Veteran’s treatment records indicate that the Veteran manifested left knee symptomology throughout the period on appeal. The Veteran underwent a VA examination in February 2015. The Veteran reported that his left knee disability had increased in severity, and that currently he manifested constant pain that increased in severity with prolonged standing. When asked to describe additional functional impairment including due to flare-ups, the Veteran reported difficulty running, using stairs, moving from a seated to a standing position, or difficulty standing. The Veteran’s flexion was limited to 75 degrees, and the Veteran’s flexion was limited to 15 degrees. The Veteran was able to perform three repetitions of range of motion testing without additional loss of range of motion. The examiner opined that the Veteran’s reported additional functional loss was consistent with the examination results. The examiner further opined that additional functional impairment reduced the Veteran’s flexion to 65 degrees but did not alter the Veteran’s extension. The examiner indicated that the Veteran did not have a diagnosis of recurrent subluxation, lateral instability, a cartilage condition, or a tibial or fibular impairment. The examination report was silent for ankylosis or genu recurvatum. The Veteran testified at a personal hearing before the Board in June 2018. The Veteran reported that his left knee had gotten worse. The Veteran also indicated that his left knee resulted in difficulty performing physical activity including standing and walking. See Transcript. The Veteran underwent another VA examination in December 2019. The Veteran reported swelling, fluid build-up, and difficulty standing and walking. The Veteran reported severe flare-ups after physical activity. The Veteran’s flexion was to 80 degrees, and the Veteran’s extension was to zero degrees. The Veteran was able to perform repetitive range of motion testing without additional loss of range of motion. The examiner reported that the Veteran’s reported flare-ups were consistent with the examination results. The examiner opined that additional functional loss limited the Veteran’s flexion to 75 degrees while the Veteran’s extension remained unaffected. The examiner indicated that the Veteran did not have a diagnosis of ankylosis, recurrent subluxation, lateral instability, a cartilage condition, an impairment of the tibia or fibula, or genu recurvatum. The weight of the evidence of indicates that the Veteran is not entitled to a disability rating in excess of 20 percent due to limited extension, a disability rating of 20 percent due to limited flexion, or multiple compensable disability ratings for limitation of motion at any time during the pendency of the appeal. In order to meet the criteria for a disability rating in excess of 20 percent, the Veteran needed to manifest an extension limited to 20 degrees or more or a flexion limited to 15 degrees or less. In order to meet the criteria for multiple compensable disability ratings for limitation of motion, the Veteran needed to manifest an extension limited to 10 degrees or more and a flexion limited to 45 degrees or less. The Veteran’s range of motion was measured multiple times throughout the period on appeal, but the Veteran did not meet these criteria. In evaluating disabilities of the musculoskeletal system however, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, or atrophy of disuse are relevant factors in regard to joint disability. 38 C.F.R. § 4.45. Even if range of motion was slightly limited by pain however, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but pain itself does not constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Id. The Veteran is not entitled to increased disability ratings or additional compensable disability ratings even after consideration additional functional impairment. The Veteran is clearly manifesting additional functional impairment. In February 2015, a VA examiner opined that the Veteran’s additional functional impairment reduced the Veteran’s flexion by 10 degrees, and, in December 2019, a VA examiner opined that the Veteran’s additional functional impairment was reduced by five degrees. Even taking this additional functional impairment into consideration however, the Veteran’s range of motion measurements still do not meet the criteria for increased disability ratings or additional compensable disability ratings. The Veteran’s flexion was to 80 degrees, and the Veteran’s extension was to zero degrees. The Veteran was able to perform repetitive range of motion testing without additional loss of range of motion. The examiner reported that the Veteran’s reported flare-ups were consistent with the examination results. The examiner opined that additional functional loss limited the Veteran’s flexion to 75 degrees while the Veteran’s extension remained unaffected. The examiner indicated that the Veteran did not have a diagnosis of ankylosis, recurrent subluxation, lateral instability, a cartilage condition, an impairment of the tibia or fibula, or genu recurvatum. Here, the weight of the probative evidence of record fails to demonstrate that the Veteran is entitled to an increased disability rating for a left knee disability during the pendency of the appeal. Therefore, the evidence in this case is not evenly balanced enough so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to a disability rating in excess of 20 percent for a left knee disability rating is denied.. REASONS FOR REMAND 1. Service connection for sleep apnea is remanded. At issue is whether the Veteran is entitled to service connection for sleep apnea. The Veteran underwent a VA examination in December 2019 which indicated that the Veteran’s sleep apnea was not due to a period of service, because the Veteran’s sleep apnea was due to the Veteran’s obesity. As previously noted however, diseases may be granted on a secondary basis when obesity serves as an intermediate step between a previously service-connected disability and a disability claimed as secondary to a previously service-connected disability. VAOPGCPREC 1-2017. The Veteran has been assigned multiple disabilities for orthopedic and neurological conditions throughout his body which limit the Veteran’s ability to exercise. See April 2020 Rating Decision Code Sheet. Once VA undertakes the effort to provide the Veteran with a VA examination, VA must provide the Veteran with an adequate one, and an adequate examination is sufficiently detailed in order to ensure that VA’s evaluation of the Veteran’s claim is fully formed. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, this matter must be remanded in order to determine whether or not the Veteran’s meets the criteria for service connection on a secondary basis where obesity serves as a linking condition. 2. Service connection for a respiratory disability to include COPD, RLD, and tuberculosis is remanded. At issue is whether the Veteran is entitled to service connection for a respiratory disability to include COPD, RLD, and tuberculosis. The Veteran has alleged that his respiratory disability is related to his sleep apnea, and, in February 2019, the Board has previously found this contention sufficient to remand both issues for further development. As, further development for the Veteran’s claim for sleep apnea might lead to additional development of the Veteran’s claim for a respiratory disability, and this issue must be remanded as well in order to avoid piecemeal appellate litigation of inextricably intertwined issue. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: Arrange to provide the Veteran with a VA examination in order to address the following: (a.) Is it at least as likely as not (50 percent or more) that any of the Veteran’s previously service-connected disabilities to include any combination thereof caused the Veteran to be obese? Why or why not? (b.) Is it at least as likely as not (50 percent or more) that obesity was a substantial factor in the Veteran developing sleep apnea? Why or why not? (c.) Is it at least as likely as not (50 percent or more) that the Veteran’s sleep apnea would not have occurred but for the Veteran’s obesity? Why or why not? (d.) What is the medical significance, if any, of any opinion offered in response to questions (a.), (b.), & (c.) on the etiology of the Veteran’s claimed respiratory disability to include COPD, RLD, and tuberculosis? Why? DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David R. Seaton, Counsel 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.