Citation Nr: 21002685 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 10-34 199 DATE: January 14, 2021 ORDER An effective date prior to November 20, 2009 for the award of a total disability rating based on individual unemployability (TDIU) is denied. REMANDED Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a right upper extremity disorder is remanded. Entitlement to service connection for a left upper extremity disorder is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for right lower extremity peripheral neuropathy is remanded. Entitlement to service connection for left lower extremity peripheral neuropathy is remanded. Entitlement to service connection for the residuals of asbestosis exposure, also claimed as lung cancer, is remanded. Entitlement to an extension of a temporary total evaluation because of treatment for a service-connected condition requiring convalescence is remanded. Entitlement to extension of special monthly compensation (SMC) based on being housebound is remanded. THE VETERAN’S CONTENTIONS The Veteran seeks an earlier effective date for his award of TDIU. See April 2015 notice of disagreement (NOD). In regard to employment, at the August 2011 Board hearing, the Veteran testified that he was not employed and that he had retired from General Motors, not due to his disability, but due to the time he had worked. See August 2011 Board hearing transcript, pp. 12-13. In his February 2014 Application for Increased Compensation Based on Unemployability, the Veteran stated that he last worked and became too disabled to work due to his wounded right leg in October 2007; his last position was as a driving instructor. In his September 2017 Application for Increased Compensation Based on Unemployability, he contended that his wounds from Vietnam as well as PTSD prevented him from securing or following any substantially gainful occupation, and that his last position was as a laborer in October 2007. He seeks entitlement to extraschedular TDIU. See April 2015 NOD. The Veteran asserts that his cervical spine disability was incurred in service. See January 2013 statement in support of claim. In his November 2013 NOD, he stated that, while serving in Vietnam, he suffered the explosive effects of a B-40 rocket and was rolled 15 feet or more, as a result of which he injured his neck. See also October 2013 statement; August 2015 statement. The Veteran contends that neuropathy in his left and right arm and fingers is a directly service-connected disability. See January 2013 statement in support of claim; November 2013 NOD. He also contends that his neuropathy is secondary to his neck and back conditions. See August 2015 statement. He asserts that VA erred by failing to weigh whether his neuropathy is secondary to his neck and back conditions which have a clear link to service and are known to cause neuropathy. Id. The Veteran contends that his acid reflux is a directly service-connected disability and possibly secondary to his service-connected PTSD. See May 2012 statement in support of claim; November 2013 NOD. In his November 2013 NOD, he cited to several articles showing a relationship between PTSD, physical health, and gastrointestinal problems. He stated that research indicates that a psychological comorbidity is common among patients with GERD and that patients with gastrointestinal conditions demonstrate significantly higher anxiety and depression scores as compared with normal subjects, and he cites to medical literature showing the relationship between GERD and PTSD. See August 2015 statement. He also maintains that his erectile dysfunction is a directly service-connected disability and also possibly secondary to his service-connected PTSD. He stated that he had been treated for this condition since 2006. See May 2012 statement in support of claim; November 2013 NOD. He contended that there is a known interrelationship between PTSD and sexual dysfunction and cited to authoritative articles from contemporary medical literature in support of this claim. See November 2013 NOD; August 2015 statement. The Veteran asserts that neuropathy of his feet is a directly service-connected disability, and that he has been treated for this condition since 2006. See May 2012 statement in support of claim. The Veteran contends that service connection for asbestosis is warranted as he had exposure while in service due to asbestos insulation in the barracks and military buildings; his work in a motor pool in Germany; and his work repairing the road and military vehicles involving clutches, brakes, and engine compartment insulation. See March 2018 claim. He contended that he breathed asbestos in daily during service. See March 2018 statement in support of claim; June 2018 NOD; May 2020 VA Form 9. The Veteran also seeks to extend his temporary 100 percent rating for his lumbar spine surgery due to a lumbar fusion in April 2018; and entitlement to special monthly compensation based on housebound criteria. See April 2018 claim; June 2018 NOD; May 2020 VA Form 9. FINDING OF FACT Prior to November 20, 2009, the Veteran’s service-connected disabilities did not preclude him from securing or maintaining substantial gainful employment. CONCLUSION OF LAW The criteria for entitlement to a TDIU, including on an extraschedular basis, prior to November 20, 2009 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the United States Army from August 1969 to April 1972. This case comes before the Board of Veterans’ Appeals (Board) on appeal from November 2013 and May 2018 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In an April 2017 decision, the Board denied service connection for GERD, erectile dysfunction, and bilateral peripheral neuropathy of the lower extremities. The Veteran appealed the Board’s April 2017 decision to the Court of Appeals for Veterans Claims (CAVC), which, in September 2018, issued a memorandum decision vacating the April 2017 Board decision to the extent that it denied service connection for GERD, erectile dysfunction, and bilateral peripheral neuropathy of the lower extremities, and remanded the claims to the Board. In a May 2018 decision, the Board denied service connection for a cervical spine disability. The Veteran appealed the Board’s May 2018 decision to CAVC, which in a March 2019 order, granted the parties’ joint motions for partial remand (JMPR), vacating the Board’s May 2018 decision and remanding the claim for compliance with the terms of the JMPR. Subsequently, the issues of service connection for a cervical spine disability, GERD, erectile dysfunction, and bilateral peripheral neuropathy of the lower extremities were remanded by the Board in September 2019. In January 2020, the Board remanded the issues of entitlement to service connection for a right upper extremity disorder, a left upper extremity disorder, and entitlement to TDIU prior to November 20, 2009. The Board notes that in August 2011, the Veteran was afforded a Travel Board hearing. In April 2016, the Board notified the Veteran that the Veterans Law Judge conducting the August 2011 hearing had retired and afforded him another opportunity to have a hearing. Later that same month, he responded that he did not want another hearing. TDIU In an April 2017 decision, the Board granted TDIU for the period from May 29, 2014 to December 1, 2015. In a May 2018 rating decision, the RO granted TDIU effective May 18, 2012. In a May 2018 TDIU application, the Veteran reported that his right leg injuries in service prevented him from working. As the claim period for the right knee extended prior to May 18, 2012, the January 2020 Board decision determined that the Board has jurisdiction over TDIU for the period preceding the award of TDIU. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran is currently in receipt of TDIU effective November 20, 2009. The issue on appeal before the Board is entitlement to TDIU on an extraschedular basis prior to November 20, 2009. As the Veteran initially filed his claims for entitlement to service connection on November 26, 2008, the Board will consider the evidence dated since November 26, 2008. A TDIU may be assigned, if the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability it is ratable at 60 percent or more, and that if there are two or more such disabilities at least one is ratable at 40 percent or more and the combined rating is 70 percent or more. 38 C.F.R. § 4.16(a). The following will be considered as one disability for the purpose of meeting the foregoing rating requirements: (1) disabilities of one or both upper or lower or one or both lower extremities, including the bilateral factor if applicable; (2) disabilities resulting from a common etiology or a single accident; (3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; (4) multiple injuries incurred in action; or, (5) multiple disabilities incurred as a prisoner of war. 38 C.F.R. § 4.16(a). Prior to November 20, 2009, the Veteran’s service connected disabilities are: 1) right knee lateral compartment arthritis rated 10 percent disabling from November 26, 2008; 2) scar as a residual of shrapnel injury to right knee, right thigh, and right buttock rated 20 percent disabling from November 26, 2008; 3) degenerative disc disease of the lumbar spine, rated 10 percent disabling from November 26, 2008; and 4) noncompensable hearing loss from November 26, 2008. Prior to November 20, 2009, the Veteran’s combined rating is 40 percent. Accordingly, the Board finds that the Veteran does not meet the schedular requirements for an award of an award of TDIU pursuant to 38 C.F.R. § 4.16(a) prior to November 20, 2009. Where the percentage requirements of 38 C.F.R. § 4.16(a) are not met, entitlement to TDIU on an extraschedular basis may be considered. 38 C.F.R. § 4.16(b). The claim must first be referred to the Director for extraschedular consideration. Id. Thereafter, the Board may review the decision of the Director and make an independent determination on the matter. Wages v. McDonald, 27 Vet. App. 233, 238 (2015) (holding that the Board conducts de novo review of the Director’s decision denying extraschedular consideration). In determining whether an appellant is entitled to a total disability rating based upon individual unemployability, neither a veteran’s nonservice-connected disabilities nor his or her advancing age may be considered. 38 C.F.R. §§ 3.341(a), 4.19. Factors to be considered are a veteran’s education, employment history, and vocational attainment. See Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). For a veteran to prevail on a TDIU claim, the record must reflect some factor that takes the claimant’s case outside the norm. The sole fact that a veteran is unemployed or has difficulty finding employment is not enough, since a high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. Rather, the question is whether the claimant is capable of performing the physical and mental acts required for employment, not whether the claimant can find employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The issue is whether the Veteran’s service connected disabilities prior to November 20, 2009, which include: right knee lateral compartment arthritis rated 10 percent disabling from November 26, 2008; scar as a residual of shrapnel injury to right knee, right thigh, and right buttock rated 20 percent disabling from November 26, 2008; degenerative disc disease of the lumbar spine, rated 10 percent disabling from November 26, 2008; and noncompensable hearing loss from November 26, 2008, prevented him from working prior to November 20, 2009. In his TDIU applications, the Veteran indicated that he stopped working in October 2007, prior to the beginning of the claims period in November 2008. His applications note that his last position was a driving instructor and a laborer and that he stopped working due to his wounded right leg. He later asserted that he stopped working due to wounds from Vietnam and PTSD. See May 2018, September 2017, December 2017, and February 2014 Veteran’s Application for Increased Compensation Based on Unemployability. His applications note that he has a high school education, and no other work experience is noted aside from his work as a driving instructor from 2002 to 2007. A March 2009 VA spine examination shows that the Veteran reported pain all the time in the right buttock area, anterior thigh, and groin region. He noted that he could walk one block and did not have problems with activities of daily living. He stated that he had not worked in 18 months and that he previously worked as a truck driver. He reported that he could not go up and down the steps and could not control his leg when trying to push on the pedals and clutch. He also reported that he could not stand for prolonged periods of time. He stated there were no other limitations regarding his job. The examination report specifically noted that the Veteran was not limited in his job by his back, but was not working. At the Veteran’s February 2010 posttraumatic stress disorder (PTSD) VA examination, the Veteran reported that his usual occupation was a truck driver and that he retired in 2007 due to both his right leg condition and because the work slowed down and he was never called back. At the August 2011 Board hearing, the Veteran testified that he was not employed. He stated that he retired from General Motors because he “had the time in.” See August 2011 Board hearing transcript, p.13. When asked whether he had to retire because of his disabilities, he stated “No.” Id., p. 12. Social Security Administration (SSA) records show that the Veteran was determined to be disabled effective August 16, 2009 due to disorders of the back and other and unspecified arthropathies. The SSA records show that he reported that he stopped working in October 2007 because he went on retirement, but that his conditions became severe enough to keep him from working on August 1, 2008. The claim was referred to the Director, Compensation Services for consideration of entitlement to a TDIU on an extraschedular basis prior to November 20, 2009. The Director of the Compensation Service determined that extraschedular entitlement to TDIU was not warranted. She stated that a thorough review of the file found that, due to the Veteran’s knee condition, he had difficulties climbing the ladders of a truck and could not control his leg when trying to push on the pedals and clutch. She observed that the Veteran was initially noted to not have employment limitations due to his back; however, it was later noted that his back made it more difficult to lift, bend and walk. She stated that the Veteran’s other conditions were not noted to cause limitations on employment. The Director, Compensation Services ultimately determined that, although the evidence does show some limitations due to his service-connected disabilities, the preponderance of the evidence does not show that the Veteran was unable to obtain or maintain gainful employment due to his service-connected disabilities prior to November 20, 2009. Due to the lack of medical evidence showing the Veteran’s functional limitations in regard to his employment prior to November 20, 2009, and the negative opinion provided by the Director, Compensation Services, the Board finds that the evidence of record does not establish that the Veteran was precluded from securing or following a substantially gainful occupation as a result of a service-connected disabilities prior to November 20, 2009. Although the Board is grateful to the Veteran for his service and regrets that a more favorable outcome could not be reached, the Board finds that, an award of an extraschedular TDIU is not warranted prior to November 20, 2009. REASONS FOR REMAND 1. Cervical Spine In September 2019, the Board remanded the issue of entitlement to service connection for a cervical spine disability, also claimed as a neck condition. The Board explained that the parties to the JMPR agreed that the Board had failed to account for the Veteran’s combat status and failed to make a finding as to whether his lay statements were sufficient to establish service connection. Accordingly, in September 2019, the Board remanded this issue to obtain a VA addendum opinion to address the etiology of the Veteran’s cervical spine disability. The September 2019 Board remand noted that the examiner should specifically give consideration to the Veteran’s contentions regarding the injury to his neck in service as reflected in his November 2013 NOD. In the Veteran’s November 2013 NOD, he stated that, while serving in Vietnam, he suffered the explosive effects of a B-40 rocket and was rolled 15 feet or more. Pursuant to the Board’s remand directives, an addendum opinion was obtained in July 2020. The examiner noted a diagnosis of degenerative disc disease and arthritis of the cervical spine, and provided a negative nexus opinion. However, the Board finds this addendum opinion is inadequate for adjudication purposes as the VA examiner not specifically give consideration to the Veteran’s contentions regarding the injury to his neck in service as reflected in his November 2013 NOD. A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand. Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that there has not been substantial compliance with the prior September 2019 Board remand directives. Accordingly, the Board must remand the matter again for a VA addendum opinion. In ordering remand in the instant case, the Board is not making a preliminary formal finding as to the credibility of the Veteran’s lay reports regarding his cervical spine injury in service. Rather, the Board is merely requesting that the clinician on remand consider the Veteran’s own descriptions of the history of his cervical spine condition. See Smith v. Wilkie, 32 Vet. App. 332, 338-39 (2020). 2. Right and left upper extremity disorder An April 2013 private medical record showed diagnoses of moderate to severe sensory greater than motor left carpal tunnel syndrome, moderate right sensory carpal tunnel syndrome, and mild ulnar neuropathy suggestive of cubital tunnel syndrome with focal slowing across the elbow. The March 2019 VA examination showed diagnoses of bilateral carpal tunnel status post-surgery. However, the March 2019 VA examiner determined that there was no objective evidence of bilateral carpal tunnel syndrome or ulnar neuropathy at the time of the examination, and a negative nexus opinion was provided. In January 2020, the Board remanded these issues to obtain a VA medical opinion to determine the etiology of the Veteran’s right and left upper extremity disorders. Pursuant to the remand directives, a VA medical opinion was obtained in October 2020 and a negative nexus opinion was provided. However, the October 2020 VA examiner did not consider secondary service connection. As the Veteran contends that his neuropathy is secondary to his neck condition, a VA addendum opinion is warranted to seek an opinion on secondary service connection. See Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). 3. GERD In September 2019, the Board remanded the issue of entitlement to service connection for GERD, also claimed as acid reflux, to include as secondary to PTSD. The Board explained that CAVC noted that the September 2013 examiner’s opinion relied in part on the fact that his GERD manifested years after the triggering traumatic event, but pointed out that the Veteran was not diagnosed with his mental condition until 37 years after his service. The Board noted that, given the delay in the diagnosis of the underlying mental condition, CAVC found it unclear why a positive nexus opinion required an earlier development of GERD symptoms. Accordingly, the Board remanded this issue to obtain a VA addendum opinion to address the etiology of the Veteran’s claimed GERD disability, to include whether it was caused or aggravated by his service-connected PTSD. The Board remand specifically noted that the examiner must consider the Veteran’s GERD in related to his more contemporaneous PTSD diagnosis. Pursuant to the Board’s remand directives, an addendum opinion was obtained in July 2020 and a negative nexus opinion was provided. The Board finds this addendum opinion is inadequate for adjudication purposes as the July 2020 clinician’s rationale is similar to the rationale provided by the September 2013 VA examiner, and does not adequately consider the Veteran’s GERD in relation to his more contemporaneous PTSD diagnosis. A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand. Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that there has not been substantial compliance with the prior September 2019 Board remand directives. Accordingly, the Board must remand the matter again for a VA addendum opinion on the etiology of the Veteran’s GERD. In rendering an opinion, the clinician must acknowledge and consider the medical articles discussed in the Veteran’s November 2013 NOD and submitted by the Veteran in support an etiological relationship between GERD and PTSD. See November 2013 NOD; January 2014 Correspondence. 4. Erectile dysfunction In September 2019, the Board remanded the issue of entitlement to service connection for erectile dysfunction, to include as secondary to PTSD. The Board explained that the September 2013 examiner’s opinion relied in part on the fact that his erectile dysfunction manifested years after the triggering traumatic event, but pointed out that the Veteran was not diagnosed with his mental condition until 37 years after his service. The Board noted that, given the delay in the diagnosis of the underlying mental condition, CAVC found it unclear why a positive nexus opinion required an earlier development of erectile dysfunction symptoms. Accordingly, the Board remanded this issue to obtain a VA addendum opinion to address the etiology of the Veteran’s claimed erectile dysfunction, to include whether it was caused or aggravated by his service-connected PTSD. The Board remand specifically noted that the examiner must consider the Veteran’s erectile dysfunction in related to his more contemporaneous PTSD diagnosis. Pursuant to the Board’s remand directives, an addendum opinion was obtained in July 2020 and a negative nexus opinion was provided. The Board finds this addendum opinion is inadequate for adjudication purposes as the July 2020 clinician’s rationale is similar to the rationale provided by the September 2013 VA examiner, and does not adequately consider the Veteran’s erectile dysfunction in relation to his more contemporaneous PTSD diagnosis. A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand. Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that there has not been substantial compliance with the prior September 2019 Board remand directives. Accordingly, the Board must remand the matter again for a VA addendum opinion to address the etiology of the Veteran’s erectile dysfunction. In rendering an opinion, the clinician must acknowledge and consider the medical articles discussed in the Veteran’s November 2013 NOD and submitted by the Veteran in support an etiological relationship between erectile dysfunction and PTSD. See November 2013 NOD; January 2014 Correspondence. Additionally, the Board notes that service connection is in effect for prostate cancer. An August 2018 VA examination noted that the Veteran had erectile dysfunction and that this was part of the normal aging process, onset eight years before the diagnosis of prostate cancer. However, the opinion does not address whether the Veteran’s erectile dysfunction is aggravated by his prostate cancer. On remand, this must be addressed by the VA examiner. 5. Peripheral neuropathy of the right and left lower extremities In September 2019, the Board remanded the issue of entitlement to service connection for bilateral peripheral neuropathy of the lower extremities. The Board explained that in the September 2018 Memorandum Decision, CAVC determined that the Board erred by failing to return the September 2013 nerves examination for clarification. CAVC pointed to the fact that the examiner checked boxes indicating loss of sensation at the lower extremity associated with L5, a part of the spine for which service connection is currently in effect. CAVC found that, in granting the Veteran service connection for degenerative joint disease, the Board failed to note how then the peripheral neuropathy was attributable to something other than service, either the Veteran’s shrapnel wounds or service-connected degenerative joint disease. Accordingly, the Board remanded the issue to obtain a VA addendum opinion to address the etiology of the Veteran’s peripheral neuropathy of the bilateral lower extremities, to include consideration of secondary service connection. Pursuant to the Board’s remand directives, an addendum opinion was obtained in July 2020 and a negative nexus opinion was provided. However, the Board finds this VA medical opinion is inadequate for adjudication purposes as it does not acknowledge and consider the September 2013 VA examination showing loss of sensation at the lower extremity associated with L5, a part of the spine for which service connection is currently in effect. A remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand. Stegall v. West, 11 Vet. App. 268 (1998). The Board finds that there has not been substantial compliance with the prior September 2019 Board remand directives. Accordingly, the Board must remand the matter again for a VA addendum opinion. On remand, the VA examiner must specifically acknowledge and consider the September 2013 VA examination showing loss of sensation at the lower extremity associated with L5, a part of the spine for which service connection is currently in effect. The VA examiner must also acknowledge and consider the Veteran’s complaint in his medical record that his lumbar pain radiated to his buttocks, groin, and down his bilateral legs. See June 2016 private treatment record. In ordering remand in the instant case, the Board is not making a preliminary formal finding as to the credibility of the Veteran’s lay reports. Rather, the Board is merely requesting that the clinician on remand consider the Veteran’s own descriptions of the history of his peripheral neuropathy of the bilateral lower extremities. See Smith v. Wilkie, 32 Vet. App. 332, 338-39 (2020). 6. Service connection for asbestosis exposure, also claimed as lung cancer; an extension of a temporary total evaluation because of treatment for a service-connected condition requiring convalescence; and an extension of special monthly compensation based on housebound The Board notes that the agency of original jurisdiction (AOJ) last issued a statement of the case (SOC) on these issues in April 2020. Since then, VA treatment records have been associated with the claims file. A subsequent supplemental statement of the case (SSOC) was not issued by the AOJ, as required by 38 C.F.R. § 19.31(b)(1). The Board finds that it would be prejudicial to review this evidence in the first instance and the claims must be remanded to the AOJ for the issuance of a SSOC. The matters are REMANDED for the following action: 1. Readjudicate the Veteran’s claims of entitlement to service connection for asbestosis exposure, also claimed as lung cancer; an extension of a temporary total evaluation because of treatment for a service-connected condition requiring convalescence; and an extension of special monthly compensation based on housebound in light of the additional evidence associated with the claims file subsequent to the most recent SOC on these issues in April 2020 SOC. If any benefit sought remains denied, issue a SSOC to the Veteran and his representative and afford them an opportunity to respond. 2. Forward the Veteran’s claims file to an appropriate VA clinician to provide a medical opinion regarding the nature and etiology of the Veteran’s cervical spine condition. The entire claims file should be made available to and be reviewed by the clinician in conjunction with this request. If the clinician believes that a physical examination should be conducted in order to provide the requested opinion, one should be provided. Thereafter, the clinician should please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s cervical spine condition had its onset in, was caused by, or is otherwise related to service. For the purpose of providing this, please accept as valid the Veteran’s November 2013 statement that, while serving in Vietnam, he suffered the explosive effects of a B-40 rocket and was rolled 15 feet or more, and state whether a nexus between the Veteran’s cervical spine condition and his service is medically consistent with the information provided by the Veteran. (The Board reminds the Veteran that in asking the examiner to accept the history he provided, the Board is not at this time making an assessment of the credibility of his statements). In offering any opinion, the clinician should consider medical and lay evidence dated both prior to and since the filing of the claim (February 2013). The clinician should provide a complete rationale for any opinion rendered must be provided. If he or she cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why that is so. 3. Forward the Veteran’s claims file to an appropriate VA clinician to provide a medical opinion regarding the nature and etiology of the Veteran’s right and left upper extremity disorders. The entire claims file should be made available to and be reviewed by the clinician in conjunction with this request. If the clinician believes that a physical examination should be conducted in order to provide the requested opinion, one should be provided. Thereafter, the clinician should address the following: a.) Diagnose all right and left upper extremity disorders during the appeal period, to include diagnoses of moderate to severe sensory greater than motor left carpal tunnel syndrome, moderate right sensory carpal tunnel syndrome, and mild ulnar neuropathy suggestive of cubital tunnel syndrome with focal slowing across the elbow. b.) Please state whether it is at least as likely as not (50 percent probability or more) that any right and/ or left upper extremity disorder had its onset in, was caused by, or is otherwise related to service. c.) Please state whether it is at least as likely as not (50 percent probability or more) that any right and/ or left upper extremity disorder is caused by the Veteran’s neck condition. d.) Please state whether it is at least as likely as not (50 percent probability or more) that any right and/ or left upper extremity disorder is aggravated by his neck condition. 4. Forward the Veteran’s claims file to an appropriate VA clinician to provide a medical opinion regarding the nature and etiology of the Veteran’s GERD. The entire claims file should be made available to and be reviewed by the clinician in conjunction with this request. If the clinician believes that a physical examination should be conducted in order to provide the requested opinion, one should be provided. Thereafter, the clinician should address the following: a.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s GERD had its onset in, was caused by, or is otherwise related to service. b.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s GERD is caused by his service-connected PTSD. c.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s GERD is aggravated by his service-connected PTSD. In rendering the secondary opinions as outlined in (b) and (c), the examiner must consider not only the onset of the Veteran’s GERD in relation to the time passed since his separation from service but also in relation to his more contemporaneous PTSD diagnosis. 5. Forward the Veteran’s claims file to an appropriate VA clinician to provide a medical opinion regarding the nature and etiology of the Veteran’s erectile dysfunction. The entire claims file should be made available to and be reviewed by the clinician in conjunction with this request. If the clinician believes that a physical examination should be conducted in order to provide the requested opinion, one should be provided. Thereafter, the clinician should address the following: a.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s erectile dysfunction had its onset in, was caused by, or is otherwise related to service. b.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s erectile dysfunction is caused by his service-connected PTSD. c.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s erectile dysfunction is aggravated by his service-connected PTSD. d.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s erectile dysfunction is caused by his service-connected prostate cancer. e.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s erectile dysfunction is aggravated by his service-connected prostate cancer. In rendering the secondary opinions as outlined in (b) and (c), the examiner must consider not only the onset of the Veteran’s erectile dysfunction in relation to the time passed since his separation from service but also in relation to his more contemporaneous PTSD diagnosis. 6. Forward the Veteran’s claims file to an appropriate VA clinician to provide a medical opinion regarding the nature and etiology of the Veteran’s peripheral neuropathy of the bilateral lower extremities. The entire claims file should be made available to and be reviewed by the clinician in conjunction with this request. If the clinician believes that a physical examination should be conducted in order to provide the requested opinion, one should be provided. Thereafter, the clinician should address the following: a.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s peripheral neuropathy of the right and/or left lower extremity had its onset in, was caused by, or is otherwise related to service. b.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s peripheral neuropathy of the right and/or left lower extremity is caused by his service-connected shrapnel wounds. c.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s peripheral neuropathy of the right and/or left lower extremity is aggravated by his service-connected shrapnel wounds. d.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s peripheral neuropathy of the right and/or left lower extremity is caused by his service-connected degenerative disc disease of the lumbar spine. e.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran’s peripheral neuropathy of the right and/or left lower extremity is aggravated by his service-connected degenerative disc disease of the lumbar spine. The VA examiner must specifically acknowledge and consider the September 2013 VA examination showing loss of sensation at the lower extremity associated with L5, a part of the spine for which service connection is currently in effect. For the purpose of providing the opinion(s) requested in parts (d) and (e), please accept as valid the Veteran’s June 2016 statement that his lumbar pain radiated to his buttocks, groin, and down his bilateral legs, and state whether a nexus between the Veteran’s peripheral neuropathy of the right and/or left lower extremity(ies) and his service-connected lumbar spine condition is medically consistent with the information provided by the Veteran. (The Board reminds the Veteran that in asking the examiner to accept the history he provided, the Board is not at this time making an assessment of the credibility of his statements). In offering any opinion, the clinician should consider medical and lay evidence dated both prior to and since the filing of the claim (May 2012). The clinician should provide a complete rationale for any opinion rendered must be provided. If he or she cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why that is so. S.C. Krembs Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Samuelson, 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.