Citation Nr: 20026726 Decision Date: 04/17/20 Archive Date: 04/17/20 DOCKET NO. 16-07 187 DATE: April 17, 2020 ORDER New and material evidence has not been received to reopen the claim for service connection for scar over the right eye. The request to reopen this claim is denied. New and material evidence has not been received to reopen the claim for service connection for residuals of a right ankle fracture. The request to reopen this claim is denied. New and material evidence has not been received to reopen the claim for service connection for residuals of a left ankle fracture. The request to reopen this claim is denied. Service connection for a liver disorder to include hepatitis C is granted. Service connection for hypertension is granted. REMANDED Entitlement to service connection for a kidney condition, to include residuals of a left renal contusion and kidney stones is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include, major depressive disorder and post-traumatic stress disorder (PTSD) is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for a heart condition, to include ischemic heart disease is remanded. Entitlement to service connection for a respiratory deficiency with dyspnea is remanded. Entitlement to service connection for encephalopathy, to include as secondary to hepatitis is remanded. Eligibility under 38 USC Ch 35 is remanded. FINDINGS OF FACT 1. Service connection for a left and right ankle, and a right eye scar were previous denied by the RO in a decision dated July 2014. The Veteran did not appeal the decision and no new evidence pertinent to the claim was received by VA within one year from the date that the RO mailed the notice of the determination to the Veteran. 2. Evidence presented since the July 2014 rating decision does not relate to a previously unestablished fact necessary to substantiate the claims for service connection for a left and right ankle, and a right eye scar. 3. Resolving all doubt in the Veteran’s favor, his currently diagnosed hepatitis C is related to his active military service. 4. Resolving all doubt in the Veteran’s favor, his currently diagnosed hypertension onset within one year of active military service. CONCLUSIONS OF LAW 1. The July 2014 rating decision denying service connection for is final. 38 U.S.C. § 7015 (c), 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103. 2. New and material evidence has not been submitted to reopen the claim of entitlement to service connection for a left and right ankle, and a right eye scar. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156 (a). 3. The criteria to establish service connection for hepatitis C have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria to establish service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from January 1976 to January 1979 and from December 1990 to April 1991. This matter comes before the Board of Veterans Appeals (Board) on appeal from a July 2014 and June 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the electronic claims file. The Board observes that the RO had originally adjudicated several of the appellant's claims differently. However, the medical evidence of record reveals diagnoses of various disorders. Accordingly, the issues have been amended as reflected on the cover page. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). This afford the Veteran the broadest and most sympathetic review. Claims to Reopen The Board is neither required nor permitted to analyze the merits of a previously denied claim if new and material evidence has not been submitted. Butler v. Brown, 9 Vet. App. 167, 171 (1996). 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. 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) (2016). The Court has 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 Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159 (c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App. 110 (2010). In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). New and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed (including evidence received prior to an appellate decision and referred to the AOJ by the Board without consideration in that decision in accordance with the provisions of 38 C.F.R. § 20.1304 (b)(1)), will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156 (b) (2016). If VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the record when VA first decided the claim, VA will reconsider the claim as an original claim for benefits. 38 C.F.R. § 3.156 (c). Here, the evidence does not reflect the addition of any service department records since the original denial of the Veteran's claims for service connection for a left and right ankle, and a right eye scar. 1. Whether new and material evidence has been received to reopen a claim for scar over the right eye 2. Whether new and material evidence has been received to reopen a claim for residuals of a right ankle fracture 3. Whether new and material evidence has been received to reopen a claim for residuals of a left ankle fracture The RO denied service connection for left ankle, right ankle, and right eye scar in a July 2014 rating decision, finding that the evidence did not support that the condition was incurred in or caused by service. The Veteran did not file a timely notice of disagreement and no new evidence pertinent to the claim was received by VA prior to the expiration of the appeal period. Therefore, the decision became final, and in order for the Veteran's claim to be reopened, evidence must have been added to the record since the previous final denial that addresses the basis of the denial. 38 U.S.C. § 7105 (West 2015); 38 C.F.R. §§ 3.104, 3.156(b) and (c), 20.302, 20.1103 (2016). The Veteran has added testimony at the February 2020 Board hearing indicating generally that he had separate accidents during service where he injured his right and left ankles, and had a scar across the eyelid on his right eye, however, such statements are redundant of those made in connection with his original claim. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held, however, that evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented. Anglin v. West, 203 F.3d 1343, 1347 (2000); See also Bostain v. West, 11 Vet. App. 124 (1998) (lay hearing testimony that is cumulative of previous contentions considered by decision maker at time of prior final disallowance of the claim is not new evidence); Paller v. Principi, 3 Vet. App. 535, 538 (1992). Evidence received since the July 2014 rating decision is not relevant and probative as to the issues of service connection for bilateral ankle disability or a scar condition over the right eye. Therefore, these claims may not be reopened. Service connection claims Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C. § 1110 (West 2014); 38 C.F.R. § 3.303 (a) (2015). Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in active service. 38 C.F.R. § 3.303 (d) (2015). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. Hickson v. West, 12 Vet. App. 247, 252 (1999). Additionally, claims for certain chronic diseases - namely those listed in 38 C.F.R. § 3.309 (a) - benefit from a somewhat more relaxed evidentiary standard under 38 C.F.R. § 3.303 (b). A recent decision of the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court), clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303 (b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). In its determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 ; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Liver disorder, to include hepatitis The Veteran contends that his diagnosed Hepatitis C was contracted in service due to injector guns and sharing razors in service. Military personnel record shows the Veteran’s duties were to give emergency care and perform nursing care procedures to the sick and injured. Also, he performed vehicle maintenance and tasks in preparation of setting up hospitals. Medical records show diagnoses of hepatitis C, cirrhosis of the liver, and fatty liver and liver cancer. A November 2001 pathology report shows chronic hepatitis C with a grade 3 portal inflammation and interface hepatitis. The July 2014 VA examiner opined that the Veteran's hepatitis C “is not caused by or a result of active military service”. The rationale given was that “STRs are silent for diagnosis of or treatment for hepatitis C or any chronic liver disability. The veteran was diagnosed with hepatitis C greater than one year after separation from the military. The STR is silent for risk factors normally associated with hepatitis C.” The examiner added that “while exposure to hepatitis C infected body fluids through mucocutaneous and nonintact skin can be the route of exposure, the veteran's service medical record is silent for either of these exposure routes.” Unfortunately, the Board finds this rationale inadequate, as the absence of evidence is not, on its own, the evidence of absence. Moreover, the examiner fails entirely to consider the Veteran's specific allegations that he contracted hepatitis C from contaminated razors and inoculations from a shared injection gun, which VA has conceded are biologically plausible. See VA Fast Letter 04-13. The Veteran submitted an October 2014 DBQ from a private physician. Dr. P.K. diagnosed the Veteran with hepatitis C since 1981 and cirrhosis of the liver. The examiner described the history of the Veteran’s liver condition as “shared razors, jet gun immunizations, blood contact as a field medic (1976-1979), first identified by new screening test for medical personnel in approximately 1980.” The examiner remarked that the Veteran’s first liver biopsy in 1981 was interpreted as a fatty liver. In July 1983, a second liver biopsy was performed with results as “probable persistent acute or chronic persistent hepatitis. A third biopsy in November 2001 showed results of chronic hepatitis C with a grade 3 portal inflammation and interface hepatitis. Grade 2 lobular activity Stage 2 portal-portal fibrosis no distortion of the vascular architecture no obvious evidence of cirrhosis no malignancy.” In a letter from December 2016, private doctor P.J.Y., opined that the Veteran’s developed hepatitis C was more likely than not related to inoculation via the air needle procedure which evolved to be a most unsanitary and biologically dangerous procedure. He added that the Veteran as a medic was required to come into contact (with his hand) of body fluids and blood as well as body tissues without the protection of sterile gloves while serving in Germany. This in itself has a profound risk of biological contamination. In a June 2016 DBQ for hepatitis, cirrhosis and other liver conditions from the same private physician, Dr. P.K. added that in January 2014 the Veteran was currently diagnosed with advanced chronic hepatitis C with cirrhosis. Dr. P.K. opined that “based on military service, medic blood contact, jet gun inoculations and sharing razors it is more likely as not, related to military service.” The Veteran has testified at the Board hearing that he is currently receiving treatment at Mayo Clinic. The Veteran also submitted a February 2020 opinion from J.M., MD. Dr. M. reviewed the VA and private treatment records and concluded the hepatocellular carcinoma, end stage liver disease/cirrhosis, end stage kidney disease and pulmonary arterial hypertension were related to an onset in service, specifically the hepatitis C diagnosed in military caused the liver cirrhosis and liver cancer. The rationale provide was that the hepatitis C infection acquired while in military service is directly related to liver cirrhosis and liver cancer. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. Specifically, the Board could seek further rationale for the etiology of the hepatitis C and why the other liver conditions are related to service. In this case, there is a negative VA examination; however, this examination did not discuss the Veteran’s specific contentions of risk from air gun injectors and exposure to fluids while performing duties providing emergency care. While the Veteran has submitted several private nexus opinions, none of these contain a detailed rationale. However, under the law, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). Accordingly, resolving all doubt in the Veteran’s favor, the Board finds it is likely that the Veteran’s current hepatitis C and other liver disabilities are the result of or related to exposure to blood and other risk factors during service. In light of the evidence of a current disability, the credible lay evidence of an in-service, significant risk factor for hepatitis C, the medical opinions of record, and the Veteran’s lay statements, the Board finds that service connection for hepatitis C and subsequently developed liver disorders is warranted. Hypertension The Veteran seeks service connection for hypertension. He asserts such a heart condition began during active duty service or within a year thereafter, and service connection is thus warranted. A January 1993 medical record note states that the Veteran “was diagnosed with hypertension in April 1991, upon return from Saudi Arabia.” Additionally, an October 1992 report of medical history notes that the Veteran’s hypertension had its onset in 1991 upon return from Saudi Arabia and he was treated with Lotensin. The Veteran provided a July 2017 private DBQ for ischemic heart disease. The examiner noted that the Veteran has ischemic heart disease with diagnoses of coronary artery disease (CAD diagnosed in December 2013), coronary artery bypass grafting (CABG diagnosed in December 2013) and hypertension (date of diagnosis unknown). In a letter from December 2016, private doctor P.J.Y., stated that the Veteran’s hypertension is directly and causally related to his diagnosed ischemic heart disease. Dr. P.J.Y. opined that it is more likely than not that same is directly and causally related to the Veteran’s military service. A rationale was not provided. The Veteran testified that he never had problems with hypertension before his deployment to Saudi Arabia. He testified that they found out he was having issues with blood pressure during his deployment. He reported that the flight surgeon reported on a Form DD 93 that he had hypertension while he was still on active duty. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's hypertension had its onset within one year of service discharge to a compensable degree. In making this determination, the Board notes that the Veteran had elevated blood pressure readings during service, and VA has conceded that he was diagnosed with hypertension reasonably shortly following service. Significantly, the October 1992 report of medical history noted a diagnosis of hypertension and indicated treatment with medication. This was just a year and a half after service. Furthermore, this record and the January 1993 record both support the Veteran’s assertion that he was diagnosed in April 1991 upon his return from Saudi Arabia. Further, the Veteran's statements have been consistent concerning his post-service hypertension-related treatment and symptomatology. While the exact date the Veteran began taking medication is unclear, it is clear that he started treating with medication at some point prior to October 1992. The Board notes that in this case the Veteran is not providing a medical opinion but is simply stating what he experienced and observed (i.e., taking blood pressure medication beginning in 1991) concerning his post-service treatment for hypertension. See Layno v. Brown, 6 Vet. App. 465, 469 (1994) (non-expert witnesses are competent to report that which they have observed with their own senses. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In sum, the Veteran has provided a competent and credible account of having had hypertension during service and taking medication within one year of his service separation, and service connection is warranted for hypertension. REASONS FOR REMAND 1. Entitlement to service connection for a kidney condition, to include residuals of a left renal contusion and kidney stones is remanded. The Veteran claim that he has a kidney condition related to an injury he had in service when a “human pyramid” collapsed resulting in him been injured in the kidneys. He claimed to have kidney problems since then, including several episodes of kidney stones and renal failure. Service treatment records show that the Veteran was hospitalize for several days in June 1976 for a left renal contusion, acute left pyelonephritis organism Klebsiella-Enterobacter, and gram-negative sepsis suspected. VA treatment records show the Veteran underwent a liver biopsy in July 1983. The note shows that the Veteran had abnormal liver chemistries for the past two years. The Veteran underwent a VA examination for kidney conditions in May 2014. The examiner noted a diagnosis of ureterolithiasis. The Veteran reported that he was diagnosed with kidney stones while in active duty. opinion on kidney stones or other kidney disease- less likely than not caused by or as result of trauma to kidney that occurred in June 1976. The rationale given is that there is no objective medical evidence of kidney stones while on active duty. The veteran did not have any diagnostic evidence of a kidney stone while on active duty and there is no scientific evidence to support the claim that kidney stones are incurred or caused by trauma to kidney that occurred in June 1976. The opinion is not adequate because did not address whether or not the current Veteran’s kidney condition of ureterolithiasis is related to his active duty service. In a letter from December 2016, private doctor P.J.Y., stated that the Veteran’s first suffered from kidney stones while in service in Germany and that since that time he has a tendency to form pass stones with associated abdominal and back pain which is often debilitating. He opined that as the condition had a documented onset in service and persist to the present, it should be service connected. The Veteran also submitted a February 2020 opinion from J.M., MD. Dr. M. reviewed the VA and private treatment records and concluded the hepatocellular carcinoma, end stage liver disease/cirrhosis, end stage kidney disease and pulmonary arterial hypertension were related to an onset in service, specifically the hepatitis C diagnosed in military caused the liver cirrhosis and liver cancer. The rationale provide was that the hepatitis C infection acquired while in military service is directly related to liver cirrhosis and liver cancer. The Veteran, at the Board hearing, testified that he wanted to broaden his claim to a kidney condition and not limited to kidney stones. While the February 2020 opinion suggests a nexus to service or the service-connected liver disability, no rationale for the kidney disease was provided. Therefore, The Board finds that an Addendum VA examination is necessary in order to determine the nature and etiology of the Veteran's claimed kidney condition. 2. Entitlement to service connection for ischemic heart disease is remanded Pursuant to VA's duty to assist a claimant in the development of facts pertinent to the claim, a medical examination or medical opinion is considered necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent medical evidence of a currently diagnosed disability or persistent or recurrent symptoms of a disability; (2) establishes that the Veteran suffered an event, injury, or disease in service; and (3) indicates that the claimed disability or symptoms may be associated with an established event, injury or disease in service or with another service-connected disability. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c)(4). At the Board hearing the Veteran testified that he has been treated his heart, liver and kidney conditions at the Mayo Clinic. The record available shows medical records from Mayo Clinic for the liver condition, only. On remand, The RO must request these records. Furthermore, the Board believes a medical opinion is warranted in light of the grant of service connection for hypertension. 3. Service connection for encephalopathy, secondary to hepatitis C is remanded. The Veteran claims his diagnosed condition of encephalopathy is secondary to his chronic cirrhosis due to hepatitis C. The Veteran was afforded a VA examination for the central nervous system and neuromuscular diseases in May 2017. The VA examiner diagnosed the Veteran with encephalopathy secondary to chronic cirrhosis diagnosed in 2016. The examiner opined that the condition at least as likely due to the Veteran’s chronic cirrhosis as “the Veteran's current hepatic encephalopathy is consistent with long-standing significant end-stage cirrhosis. If the Veteran obtains liver transplant, he would be expected that his current hepatic encephalopathy would resolve and require no further treatment,” In a letter from December 2016, private doctor P.J.Y., stated that the Veteran’s has developed encephalopathy with associated cephalgia, confusion, disorientation, and speech impairment. The Board has remanded the claims of service connection for hepatitis C, to include a liver condition and chronic cirrhosis. Medical record from Mayo clinic are needed. The Board finds that this claim is inextricably intertwined with the remanded claims for service connection for hepatitis C. Therefore, the appropriate remedy where pending claims are inextricably intertwined with claims currently on appeal is to remand the claims on appeal pending the adjudication of the inextricably intertwined claims. Harris v. Derwinski, 1 Vet. App. 180 (1991). 4. Service connection for an acquired psychiatric condition, to include major depressive disorder and post-traumatic stress disorder (PTSD) is remanded. The Veteran contends entitlement to service connection for an acquired psychiatric disorder, to include PSTD and major depressive disorder. Specifically, he asserts that his acquired psychiatric disorder is related to his service in Desert Storm as there were bombings every night and they did not have covers over their bunkers. When he returned home, he could not sleep, or had to sleep in the couch, could not handle any load noise, like fireworks and he would wake up with nightmares. See February 2020 Board hearing. The record reflects that the Veteran underwent an initial VA examination for PTSD in May 2017. The Veteran reported his experience in Desert Storm as “they were hitting us with frog missiles and astro- rockets, they would basically shatter the compound.” The VA examiner found the Veteran do not have a diagnosis for PTSD that conforms to DSM-5 criteria. The examiner diagnosed the Veteran with major depressive disorder and other specified trauma and stressor related disorder based on the Veteran’s subjective report of symptoms. The examiner opined that “based on the records reviewed and the examination of the Veteran, it is less likely than not that the Veteran's current mental health condition is a result of an in-service stressor related event. The records do not support the mental health condition of Other Specified Trauma and Stressor Related Disorder related to military service. STRs are silent for any mental health issues/treatment. VA Records are silent for mental health treatment. Therefore, it is less than likely that the mental health condition is a result of an in-service stressor related event.” Additionally, the Veteran provided a private psychological report from December 2016. Dr. J.O.H., licensed psychologist, diagnosed the Veteran with PTSD consistent with DSM-5. As the Veteran has submitted subsequent statements regarding his acquired psychiatric disorder, the prior examinations and opinions were not based upon a complete record and are therefore inadequate. Furthermore, it appears that there are outstanding records. At his Board hearing, the Veteran testified he is currently receiving psychiatric treatment from Mayo Clinic. In addition, during the September 2019 Board hearing, the Veteran indicated that he had received psychiatric treatment when he first got out of service. There are no psychiatric records from Mayo Clinic currently associated with the claims file. As such, remand is necessary to obtain any relevant treatment records. See 38 C.F.R. § 3.159 (c). Thus, based on the foregoing, a new psychiatric examination in consideration of the Veteran's lay statements and all of the pertinent medical evidence, including any outstanding medical records, is warranted. 5. Service connection for fibromyalgia is remanded. The Veteran had service in Southwest Asia. The Veteran contends that when he was deployed in Saudi Arabia, he experienced intense itching under the skin. See February 2020 Board Hearing. However, at his May 2017 VA examination, the examiner noted that the Veteran reported that he was unaware of any current or past diagnosis of fibromyalgia, nor does he relate symptoms consistent with fibromyalgia. A diagnosis of fibromyalgia was not established and for that reason a medical opinion was not provided. In a letter from December 2016, private doctor P.J.Y., stated that the Veteran was diagnosed that morning with fibromyalgia. He opined that the aforementioned condition is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illnesses) published in Gulf War, Spring 2015. A Gulf War general examination was afforded in May 2017. The only answer provided regarding the medical history was respiratory conditions (other than tuberculosis and sleep apnea) and fibromyalgia. The examiner noted that there was not any diagnosed illness with no etiology. The Veteran did not report any additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness." On remand the examiner must address the symptoms that the Veteran has reported at the Board hearing. 1. Service connection for a respiratory condition, to include pulmonary vascular disease and pulmonary thromboembolism is remanded. The Veteran contends that he has a respiratory condition related to service. Considering first the service treatment records, these records are negative for any diagnosis of or treatment for diabetes. On June 1987 and August 1991 periodic examinations, the Veteran denied any history of sugar or albumin in his urine. Medical records show that pulmonary thromboembolism was diagnosed in 2012 Post-service, the Veteran was afforded a VA examination for respiratory conditions in May 2017. He was diagnosed with pulmonary vascular disease, pulmonary thromboembolism. The examiner noted that the Veteran was unaware of any current chronic pulmonary diagnosed disability and currently requires no care for any chronic diagnosed pulmonary disability. The examiner remarked that the veteran's pulmonary thromboembolism treated in 2012 resolved without residual and “for that reason, medical opinion is not indicated.” In a letter from December 2016, private doctor P.J.Y., stated that the Veteran is diagnosed with a respiratory deficiency, to include dyspnea, and the volume of air on the expiatory effort is compromised with wheezing and that this condition began with his Gulf War service. He opined that the aforementioned condition is directly and causally related to Gulf War Syndrome per the presumptions (undiagnosed illnesses) published in Gulf War, Spring 2015. A Gulf War general examination was afforded in May 2017. The only answer provided regarding the medical history was respiratory conditions (other than tuberculosis and sleep apnea) and fibromyalgia. The examiner noted that there was not any diagnosed illness with no etiology. The Veteran did not report any additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness." At the February 2020 Board hearing, the Veteran testified that he has symptoms of shortness of breath, tightness of the chest, limited mobility and needs oxygen at nights. The Veteran’s wife testified that his respiratory condition is related to the hepatitis C and the heart condition. “because the respiratory is connected with the heart.” 2. Eligibility to Dependents' Educational Assistance (DEA) under 38 USC chapter 35 is remanded. With regard to the Veteran's claim of entitlement to DEA, the Board finds that this claim is inextricably intertwined with the remanded claims. Therefore, the appropriate remedy where pending claims are inextricably intertwined with claims currently on appeal is to remand the claims on appeal pending the adjudication of the inextricably intertwined claims. Harris v. Derwinski, 1Vet. App. (1991). The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should contact the veteran and request that he identify the names, addresses, and approximate dates of treatment for all medical care providers, VA and non-VA, inpatient and outpatient, who may possess additional pertinent records. After obtaining any necessary authorization or medical releases, the AOJ should request and associate with the claims file legible copies of the veteran's complete treatment reports from all sources identified whose records have not previously been secured. Regardless of the Veteran's response, the AOJ should secure all outstanding VA treatment records. 2. Obtain an addendum opinion from the May 2014 VA examiner, or if unavailable, another suitably qualified examiner, as to whether it is at least as likely as not that the Veteran's current kidney condition onset in or was caused by service. The examiner must comment on the February 2020 private opinion of J.M., MD. A new examination is not required unless the examiner feels one is necessary. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. Obtain a VA examination that addresses the nature and etiology of the Veteran's heart or cardiovascular disabilities, including ischemic heart disease, and peripheral vascular disease. All indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The entire claims file, to include a complete copy of this REMAND, should be made available to the examiner designated to provide an opinion, and the examination report should include a discussion of the Veteran's documented medical history and assertions. The examiner should offer comments, an opinion and a supporting rationale for the following: (a) Identify all diagnosable cardiovascular disabilities. If the examiner finds that the Veteran does not have ischemic heart disease, or peripheral vascular disease, the examiner must clearly set forth the basis for such finding. (b) For each diagnosis identified above, is it at least as likely as not (50 percent probability or greater) that such disability began in service, was caused by service, or is otherwise etiologically related to the Veteran's service or the service-connected hypertension. c) For each diagnosis identified above, is it at least as likely as not (50 percent probability or greater) that such disability is caused or aggravated by the service-connected hypertension. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be considered. A complete rationale for all opinions is required. 4. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of any acquired psychiatric disorder. The claims file must be made available to the examiner for review. The examiner should be directed to elicit a complete history from the Veteran. The examiner should be directed to elicit a complete history from the Veteran. For any acquired psychiatric disorder diagnosed, the examiner must opine as to whether it is due to an in-service disease or injury, and if PTSD is diagnosed, the stressor(s) upon which the disability is based should be clearly identified. Additionally, for any acquired psychiatric disorder diagnosed, the examiner should provide an opinion which addresses whether it is at least as likely as not either (i) caused by, or (ii) aggravated by, the Veteran's service-connected back disability. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 5. Schedule the Veteran for an appropriate VA examination on his claimed fibromyalgia disability. The examiner should note that the claims file has been reviewed. All studies, tests, and evaluations deemed necessary by the examiner must be performed. (a) The examiner should render an opinion as to whether it is at least as likely as not that the Veteran has a current diagnosis of fibromyalgia. The examiner must discuss the Veteran’s testimony as to intense itching under the skin in service and continuing post-service and report of P.Y. indicating a diagnosis. (b) The examiner should render an opinion as to whether it is at least as likely as not that the Veteran's symptoms presents as (1) an undiagnosed illness or (2) a medically unexplained chronic multi symptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of his respiratory condition. The examiner must review the entire claims file and a copy of this Remand. The examiner is asked to identify all pertinent current diagnoses. The Board notes that the Veteran does have diagnoses of pulmonary vascular disease and pulmonary thromboembolism. The examiner should indicate whether any diagnoses are duplicative; that is, medical providers have provided different names for the same condition. For each diagnosed condition, the examiner is asked to answer whether it is at least as likely as not (a 50 percent or greater probability) that had its onset in, or is otherwise related to, the Veteran's active service. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran's lay statements. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Romero-Sanchez, Associate 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.