Citation Nr: 21004172 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 19-33 464 DATE: January 26, 2021 ORDER As new and material evidence has been received, the claim for entitlement to service connection for a headache disorder, is reopened; the claim is granted to this extent only. As new and material evidence has been received, the claim for entitlement to service connection for sleep apnea is reopened; the claim is granted to this extent only. As new and material evidence has been received, the claim for entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is reopened; the claim is granted to this extent only. Entitlement to service connection for a headache disorder, to include on a secondary basis, is granted. Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD), to include on a secondary basis, is granted. Entitlement to an evaluation of 40 percent, but no higher, for varicose veins of the left lower extremity is granted. Entitlement to an evaluation of 40 percent, but no higher, for varicose veins of the right lower extremity is granted. REMANDED Entitlement to service connection for sleep apnea, to include on a secondary basis, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. An October 2015 rating decision denied the Veteran’s claims for entitlement to service connection for a headache disorder and sleep apnea. 2. The evidence received since the October 2015 rating decision is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for a headache disorder and sleep apnea. 3. August 2016 and November 2016 rating decisions denied the Veteran’s claims for entitlement to service connection for an acquired psychiatric disorder and entitlement to service connection for PTSD. 4. The evidence received since the August 2016 and November 2016 rating decisions is neither cumulative nor redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim for service connection for an acquired psychiatric disorder, to include PTSD. 5. Resolving all reasonable doubt in favor of the Veteran, his headache disorder is causally or etiologically related to his military service. 6. Resolving all reasonable doubt in favor of the Veteran, his psychiatric disorder is related to active service. 7. Resolving all reasonable doubt in favor of the Veteran, his varicose veins of the bilateral lower extremities has been manifested by pain, persistent edema, and stasis pigmentation throughout the period on appeal; the Veteran did not have ulcerations on his bilateral lower extremities due to his varicose veins. CONCLUSIONS OF LAW 1. New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for a headache disorder. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 2. New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for sleep apnea. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 3. New and material evidence has been received sufficient to reopen the claim of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 4. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310(a). 5. The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. § 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for entitlement to a 40 percent rating for varicose veins of the left lower extremity have not been met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.22, 4.104, Diagnostic Code 7120. 7. The criteria for entitlement to a 40 percent rating for varicose veins of the right lower extremity have been met. 38 U.S.C. §§ 1155; 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.22, 4.104, Diagnostic Code 7120. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1984 to September 1988, and from February 1991 to February 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2020, the Veteran and his spouse appeared with his attorney for a videoconference hearing before the undersigned. In September 2019, the RO granted a 20 percent disability rating for the Veteran’s service-connected right and left lower extremity varicose veins, effective May 23, 2019. Thus, as higher ratings are available for these disorders, these issues remain in appellate status. See A.B. v. Brown, 6 Vet. App. 35, 38 (1993). This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107 (a)(2); 38 C.F.R. § 20.900(c). New and Material Evidence A rating action from which an appeal is not perfected becomes final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The governing regulations provide that an appeal consists of a timely filed notice of disagreement in writing, and after a statement of the case has been furnished, a timely filed substantive appeal. 38 C.F.R. § 20.200. In order to reopen a claim which has been denied by a final decision, new and material evidence must be received. 38 U.S.C. § 5108. New and material evidence means evidence not previously submitted to agency decision makers; which relates, either by itself or when considered with previous evidence of record, to an unestablished fact necessary to substantiate the claim; which is 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 which raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110 (2010). Moreover, in determining whether that low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA’s duty to assist or through consideration of an alternative theory of entitlement. As new and material evidence has been received, the claims for entitlement to service connection for a headache disorder, sleep apnea, and an acquired psychiatric disorder, are reopened; the claims are granted to this extent only. In an October 2015 rating decision, the RO denied the Veteran’s claim for service connection for a headache disorder, sleep apnea, and an acquired psychiatric disorder, finding that none of these claimed disabilities were incurred in or caused by active service. The evidence of record included service treatment records (STRs), military personnel records (MPRs), VA and private post-service treatment records dated through September 2015, a private medical opinion indicating that the Veteran’s sleep apnea was caused by his deviated septum, and a sleep apnea VA examination, indicating that the Veteran’s sleep apnea was not proximately due to or the result of his deviated septum. The Veteran was notified of the rating decision in October 2015. The Veteran filed a Notice of Disagreement (NOD) with regard to his issue of service connection for sleep apnea, and a Statement of the Case (SOC) was issued in February 2016. However, the Veteran did not certify his sleep apnea appeal to the Board and took no action regarding the other claims. Therefore, the October 2015 decision is final with regard to each of these issues. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.156(b), 3.160(d), 20.302, 20.1103. The Veteran filed a new claim for service connection for a psychiatric disorder, to include PTSD, in January 2016. An August 2016 and November 2016 rating decision denied the Veteran’s claims for service connection a psychiatric disorder and entitlement to service connection for PTSD, finding that there was no evidence of a nexus between his acquired psychiatric disorder or PTSD and active service. The Veteran did not appeal these decisions, and therefore, the August 2016 and November 2016 rating decisions are final with regard to the issues of entitlement to service connection for an acquired psychiatric disorder and PTSD. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.156(b), 3.160(d), 20.302, 20.1103. Since the October 2015 rating decision, denying the Veteran’s claims regarding a headache disorder and sleep apnea, became final, the Veteran and his spouse testified that the Veteran has experienced headaches and problems sleeping since service; additionally, he submitted lay statements from his family members and a fellow service member describing his symptoms and medical opinions from his treating providers indicating, in pertinent part, that his sleep apnea was related to his service-connected deviated septum and his headaches were related to his active service. The Veteran additionally submitted articles suggesting a relationship between his headaches and his service-connected deviated septum. Additionally, since the August 2016 and November 2016 rating decisions, denying the claims related to a psychiatric disorder and PTSD, became final, the Veteran and his spouse testified that the Veteran has experienced depression since service; additionally, he submitted lay statements from his family members describing these symptoms and a medical opinion from his treating provider indicating that his psychiatric disorder was related to military trauma. Furthermore, three VA medical opinions were obtained, each provided a positive nexus opinion. The Board finds that the low threshold requirement for new and material evidence is satisfied with respect to each of the Veteran’s claims. Shade v. Shinseki, 24 Vet. App. 110 (2010). When considering the new evidence in conjunction with the evidence already of record, it raises a reasonable possibility of substantiating the claims. Thus, the Board finds that new and material evidence has been submitted and the petition to reopen the claim of entitlement to service connection for a headache disorder, sleep apnea, and an acquired psychiatric disorder must be granted. Service Connection Establishing service connection generally requires (1) evidence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also 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 service. 38 C.F.R. § 3.303(d). Service connection for certain chronic diseases may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307, and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence, which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for a headache disorder, to include on a secondary basis, is granted. The Veteran contends that service connection is warranted for his headache disorder because his headaches started during active service after he incurred an injury to his nose. Alternatively, the Veteran contends that his headaches are due to his service-connected deviated septum. The Veteran’s entrance examination is silent for any treatment or diagnosis related to headaches. A nasal bone trauma was noted in October 1985; he was instructed to ice the injury and take Tylenol. A November 1985 notes that the Veteran had headaches and congestion for three months; the assessment only notes cold symptoms. September 1985 and September 1986 STRs note reports of difficulty breathing, and an October 1987 record notes that the Veteran underwent nasal surgery in February 1987. The Veteran’s separation examination is silent for any treatment or diagnosis for headaches, but it does note that the Veteran had nasal symptoms. An October 2012 medical treatment record notes that the Veteran had a ventriculoperitoneal shunt placed in February 2012, and he continued to have daily headaches; a February 2013 medical treatment record notes worsening headaches. The Veteran established VA care in August 2015. He reported at this time that, in 2012, he bent down, and his ears popped; he was treated for an ear infection, but the symptoms persisted. He was given antibiotics and ear drops. It was then decided that he had “water in the ears” and PE tubes were inserted in both the ears. Once the PE tubes were inserted, he started to drain a large amount of fluid on a daily basis, which was determined to be cerebral spinal fluid (CSF). He again developed chronic headaches and was referred to a neurosurgeon who inserted into the right temporal area. This alleviated his headaches for a few days, but then the headaches returned. Since 2012, he has experienced chronic daily headaches that are pressure-like in origin and has continued to be under the care of a private sector neurologist and periodically seeing a neurosurgeon. After innumerable CT scans and MRIs, his neurosurgeon determined that the original shunt was not put in the correct location and he had another shunt placed last month. The latest shunt only worked for about a week and again the headaches have resumed. He is on Topamax and gabapentin to help with his headaches. An August 2016 VA treatment record notes that, since the last revision in 2012, the Veteran has had severe headaches located primarily around the top of the head. He described the pain as sharp and pounding, 5 to 10 times per day, lasting approximately 1 to 2 minutes. He also described worsening at night when he lies down. The assessment notes that the Veteran had intracranial hypertension status post VPS in 2011 with multiple revisions since then. The provider indicated that the exact etiology of his headaches was not entirely clear at this point. The Veteran had a neurology evaluation and LP performed recently with no evidence of increased ICP, although imaging showing potential shunt valve occlusion. The provider indicated that it was difficult to say whether the history of multiple interventions and shunt revisions has caused or contributed to these persistent headaches. Presentation and distribution were not typical for any specific disorder, but the diagnosis includes atypical migraines, cluster headaches, and occipital neuralgia. Tenderness over the occipital region may indicate at least a component of occipital neuralgia, but bilateral presentation is unusual. Frequency and short time of attacks were more suggestive of neuralgia syndrome than headaches. A December 2016 correspondence from the Veteran indicates that he has suffered from severe headaches since an injury in service that resulted in a broken nose/deviated septum. He indicated that he has been using nose drops daily since this in-service injury, which deteriorated his skull bone requiring 4 surgeries to try and correct the problem and associated headaches. He indicates that he is unable to work due to his headaches. A January 2017 VA Disability Benefits Questionnaire (DBQ) notes that the Veteran had a diagnosis of migraines. The report notes that the Veteran reported that his headache symptoms began in 1986 when a tent pole fell and hit him on the head and face. He indicated that his nose bled a lot and he was given a towel with ice; he reported that he had a bruise and blockage, and a nasal fracture with a deviated septum repair upon returning state side. He indicated that, at the time of the injury, he felt dazed and confused; the headaches began at this time and have progressively worsened from this time. The examiner opined that it was less likely than not that the Veteran’s headache disorder was proximately due to or the result of the Veteran’s deviated septum because there was no documented medical record data provided by a specialist to support or add merit to this claim; nor was there any direct pathology between the two conditions to substantiate a cause and effect relationship without resorting to mere speculation. No direct service connection opinion was provided. A January 2019 statement from the Veteran’s treating psychologist indicates that the Veteran complained of severe migraines related to a traumatic brain injury incurred during active service. A November 2019 statement from the Veteran’s treating physician indicates that the Veteran had multiple head traumas during his time in service. Ever since that time, he suffered from chronic, continuous, daily, debilitating headaches. Additionally, he underwent a septoplasty surgery while in service; years later a CSF leak was discovered, which led to repair and stent. His headaches never resolved. The provider indicated that these complications are directly related to his time in the service. An associated medical record notes that the Veteran had a shunt in 2012. He had headaches prior to and since the shunt placement. A November 2019 statement from the Veteran’s spouse indicates that the Veteran suffered from chronic headaches since his in-service septoplasty; additionally, after his shunt placement, he has had headaches constantly. Additionally, the Veteran submitted medical articles in January 2020 suggesting a relationship between CFS leaks, shunts, and headaches. Another DBQ, received in January 2020, completed by the Veteran indicates that he suffered from severe headaches, bilateral headaches, and primary headaches. The Veteran indicated that he had a CSF leak related back to trauma and deviated septum surgery in service. Due to this leak, a stent was placed. An October 2020 statement from the Veteran’s treating physician notes that the Veteran had multiple head traumas during service; since that time, he suffered from chronic, continuous, daily, and debilitating headaches. Additionally, the Veteran underwent a septoplasty during service; years later a CSF leak was discovered, leading to a repair and shunt. The headaches never resolved. The physician indicated a thorough review of all available pertinent records, including his STRs. At his November 2020 Board hearing, the Veteran reported that his headaches started in 1987. He indicated that he experienced headaches just about every day, which he attributed to his difficulty breathing, and his headaches have continued every day since then. Additionally, the Veteran’s spouse indicated that she first heard the Veteran complain about headaches when he was in Japan, after his nose trauma from getting hit in the head. She indicated that he had headaches every day since then; he took over the counter medications daily, and he additionally tried alternative treatments as much as 10 or 15 years prior. After carefully reviewing and weighing the competent evidence of record, the Board is satisfied that the evidence is at least in approximate balance as to whether the Veteran’s headache disorder is directly related to service. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the Board acknowledges that none of the VA examiners provided direct service connection opinions, the record contains favorable evidence in the form of documentation of reported headaches in his STRs and the Veteran’s competent descriptions of head pain since service, which the private provider relied upon in finding that his headaches had their onset during service. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Given the nature of headaches, the Veteran is uniquely situated to competently identify and report on its onset and duration. Here, the Board finds his assertion that the headaches were incurred while in service and have continued since service is both competent and credible, and thus is positive evidence that supports a finding of nexus in this case. This supporting evidence places the pertinent record in relative equipoise. As the Board finds that the grant of service connection is warranted for the Veteran’s headache disorder on a direct basis, further analysis addressing secondary service-connection is not necessary. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Entitlement to service connection for an acquired psychiatric disorder, including PTSD, to include on a secondary basis, is granted. The Veteran contends that his current acquired psychiatric disorder is directly related to active service. Alternatively, he contends that his psychiatric disorder is due to his service-connected varicose veins. The Veteran has reported numerous incidents during service in which he attributes his current acquired psychiatric disorder, to include PTSD. Specifically, he reported that, in January 1987, a vehicle from his convoy hit an unarmed man in Korea, killing him. Additionally, he reported that in January or February 1986, he was on a field exercise protecting a hospital, which was full of dogs; he indicated that he could hear the dogs barking and crying all day and night for two weeks, and continued to have nightmares of these dogs and the feeling that he could do nothing to help them. Sometime between February and April 1987, the Veteran also indicated that, while training to become a life guard, he was held underwater by the instructor on a daily basis for 12 weeks; he feared that he would drown, and he is no longer able to go swimming and has nightmares of drowning as a result. The Veteran also reported that around January 1987 to March 1987, he was working at the chow hall and was given orders, on at least 20 occasions, to throw trash into the ocean; he reports that he feels guilty that he did not do anything to better protect the environment. He also described another incident in which he witnessed two service-members engaged in sexual acts and was asked to join them; the Veteran indicates that he refused and was forced to testify about what he saw. He indicated that the two service-members were angry, and he feared for his life; he also indicates that he no longer trusts men due to this incident. STRs are silent for any complaints, treatment, or diagnosis related to any metal health disorder or related symptoms. A September 2015 VA treatment record notes that the Veteran reported that he had been depressed for many months. In discussing the origin of his symptoms, the Veteran described growing up under the threat of violence by insurgents in El Salvador, with his mother being kidnapped and his father “almost killed”, resulting in the family moving to the United States. The Veteran additionally reported a history of physical abuse by his father, who was an alcoholic and would hit him until he was bleeding. The Veteran indicated that he joined the military to get away from home but stated that he often hated the military due to feeling overly stressed and “always being in the hardest positions.” The Veteran reported recurrent dreams about his father attacking him and about difficult experiences in the military. He additionally reported persistent hypervigilance about possible threats to his safety and his family’s wellbeing. He additionally reported panic-like symptoms when waking from bad dreams and being overly distressed by unexpected noises or events. He endorsed subjective depressed mood, frequent rumination about his perceived failings, and reduced self-worth due to his family relationships and his weight. He additionally reported that he struggled with a short temper towards family members. He denied current suicidal ideation, intent, plan, or attempts. However, he did endorse a history of transient suicidal ideation following his mother’s death. He denied any history of suicide attempts. He acknowledged that he often attempted to hide his symptoms from family members, and while the Veteran was generally quite open in discussing his concerns, it was possible that his current report may slightly underestimate his symptom severity. The Veteran denied prior history of mental health counseling. The assessment notes a provisional diagnosis of PTSD and mild to moderate major depressive disorder with anxious distress based on DSM-5 criteria. A November 2015 VA treatment record notes that the Veteran served on active duty from 1984 until 1988, then reactivated his status in 1991 and went to Persian Gulf to participate in operation Desert Storm. The Veteran spent several months in the active combat there and described his military service as stressful but denied military trauma. The Veteran reported that during his childhood, he witnessed “people’s heads being cut off”, burning cars, and burning people. The Veteran’s mother was kidnapped for 7 days when he was a young child, which was stressful and traumatic for him. He also was a victim of physical abuse by his father, indicating that the memory of it still had a significant effect on his emotional status. According to the Veteran, he came to the United States at age 13 or 14. He reported that, as a result of his difficult childhood, he began experiencing insomnia, anxiety, depression, nightmares, irritability and anger at the very early age. However, the Veteran never addressed his psychological concerns with mental health professionals. At some point in time his PCP prescribed Celexa, then changed it to Lexapro for depression and anxiety, which he has been taking for almost 23 years. The assessment notes PTSD (non-combat related); and major depressive disorder, recurrent, moderate to severe with anxious distress. A January 2016 VA treatment record notes that the Veteran first developed signs of depression and anxiety as a child. He joined the military hoping that it would help him to feel better. However, the Veteran believed that his mental condition only worsened in the service due to stress. On one occasion, the Veteran reported suicidal thoughts when he was an active duty, although he was unsure about his intentions to act on them. He apparently was not offered mental health services but was seen by the chaplain three times. A January 2016 statement from the Veteran’s treating VA physician notes that the Veteran had had a diagnosis of PTSD (non-combat related); major depressive disorder, recurrent, moderate to severe, with anxious distress; and unspecified anxiety disorder. The Veteran suffered from symptoms of anxiety, depression, and irritability. He also reported insomnia, hypervigilance, nightmares, anxiety provoked dreams related to memories of military service, low energy and impaired concentration. He was attending mental health appointments and taking psychotropic medications as prescribed but remains symptomatic. No service connection opinion was provided. A letter from the Veteran’s spouse, received in June 2016, notes that the Veteran had told her about an incident that he witnessed in service, in which two service-members were engaged in sexual acts and asked him to join. When he testified about the incident, he was scared, afraid to turn in a fellow soldier. To this day, the Veteran is constantly referring to this incident whenever he has to be alone with a man, being afraid and distrusting of men. The Veteran’s spouse indicated that she believed that this incident has caused the Veteran mental issues and severe anxiety. In a December 2016 correspondence, the Veteran reported that, due to his varicose veins, he suffers from major depression. He reported that he is self-conscience about wearing shorts, and it was embarrassing to wear stockings all the time. He reported that he took medication every night for his varicose vein symptoms, which gave him anxiety and depression. He also became irritable during these episodes. A January 2017 VA DBQ notes a diagnosis of persistent depressive disorder with anxious distress. The examiner found that the Veteran did not have any other mental disorder. After a review of the Veteran’s claims file, including medical treatment records noting diagnoses of PTSD, his lay report of how his varicose veins affected his mental health, and a thorough review of the Veteran’s reported civilian and military history, the examiner opined that it was less likely than not that the Veteran’s mental health disorder is proximately due to or the result of the Veteran’s service-connected disorder. The examiner indicated that it was at least as likely as not that his persistent depressive disorder was the result of the abuse that he experienced by his father, which was as likely as not aggravated by his current medical and financial issues. The examiner reasoned that the Veteran reported that he started struggling with his depression when he joined the military and that he joined the military to escape his father’s abuse. However, he felt like things got worse after he joined because being yelled at reminded him of the abuse he experienced from his father. In addition, his father did not like that he had joined the military and cut off contact with him. He reported that he spoke to the Chaplain two or three times for support. More recently, it appears that his medical issues, his strained relationship with his father, and his financial issues have exacerbated his symptoms. The Veteran has varicose veins which result in pain, numbness, and itchiness. Because of the pain, he has difficulties sleeping. He indicated that the varicose veins prevent him from wearing shorts because he feels that people are looking at him which makes him anxious. In addition, it prevented him from working out because it makes his condition worse. An August 2017 addendum received from the same VA examiner indicates that, after reviewing the medical records again, the examiner wished to change the opinion given in January of 2017. Specifically, after reviewing the Veteran’s enlistment papers, and while they are very difficult to read, there were no notes indicating mental health issues before the military. Therefore, there is a presumption of soundness and it is at least as likely as not that the Veteran’s diagnosed persistent depressive disorder with anxious distress is a result of his military service. It appears at least as likely as not that this condition has been aggravated by his current medical (varicose veins) and financial issues. There is no documentation or evidence of a mental health disorder prior to the military. The Veteran reported that he began to struggle with depression when he joined the military and that he joined the military to escape his father’s abuse. However, he felt like things got worse after he joined because being yelled at reminded him of the abuse that he experienced from his father. In addition, his father did not like that the Veteran had joined the military and cut off contact with him. He reported that he spoke to the Chaplain two to three times for support. More recently, it appears that his medical issues, his strained relationship with his father, and his financial issues have exacerbated his symptoms. In a December 2017 VA addendum, the same VA examiner opined that it is at least as likely as not that the Veteran’s persistent depressive disorder is a result of an event in service because he reported being yelled at, reminding him of the abuse that he experienced by his father. He reported a history of trauma prior to the military and past medical records show that he struggled with depression prior to the military; however, because there is no record of this on his enlistment examination, there is a presumption of soundness. There were limited STRs, therefore, this was based on the Veteran’s reported history. Additionally, the Veteran reported that his varicose veins resulted in pain, numbness, and itching; because of the pain, he had difficulty sleeping. He also avoided wearing shorts because he is anxious about people looking at him. Additionally, he reported that he was unable to work out because it made the condition worse. These factors exacerbate his depression. It is impossible to separate out which symptoms are attributable to is relationship and financial issues versus those symptoms attributable to his varicose veins without resorting to mere speculation. A December 2018 statement from the Veteran’s father indicates that the Veteran drastically changed since his military service. He reported that, prior to service, the Veteran was social, enjoyed daily activities, and the family was close; now, the family is distant and cold, and it is obvious that his nervousness and anxiety was brought on from trauma in the service. When he said he was going to join the service, the Veteran’s father indicated that he was proud; however, as the years went on, his personality changed, and their relationship was hurt. His physical health has also deteriorated since the service. It was without a doubt that the Veteran’s service changed his physical and mental health. A statement from the Veteran’s daughter, received in December 2018, notes that, since she was young, she had to be cautious with her father’s paranoia and triggers. Another statement from the Veteran’s other daughter, also received in December 2018, also indicates that the Veteran’s trauma during service had an effect on his mental status. Both statements also provided some specific examples regarding his symptoms. A January 2019 statement from the Veteran’s treating psychologist notes that the Veteran had diagnoses of PTSD and major depressive disorder. The provider indicated that the Veteran reported symptoms of hypervigilance, depressed mood, low energy, lack of motivation and impaired sleep due to military related nightmares, bouts of extreme anger and despair related to military service, as well as anxiety, difficulty concentrating, difficulty trusting others, suspiciousness, guilt and shame related to his military trauma. There is no doubt that the Veteran’s mental illness has significantly impacted his ability to function on a daily basis and his ability to excel in vocational pursuits. An October 2019 VA treatment record notes that the Veteran expressed frustration about the denial of his VA claim. The Veteran discussed the details of his adverse military experiences that had a significant effect on his adult life. The Veteran admitted that he dealt with negative memories of childhood even before he joined the military, so he did not believe they impact his thinking as an adult. A November 2019 letter from the Veteran’s treating provider notes that the Veteran had diagnoses of PTSD, MDD, and unspecified anxiety disorder. The Veteran complained of symptoms of depressed mood, high level of frustration, increased level of anxiety, increased irritability and anger, intense hypervigilance, easy startle, intrusive memories of military trauma, emotional numbness and detachment, frequent nightmares, interrupted sleep pattern, social isolation and withdrawal, variable appetite, low energy, impaired concentration, and fleeting suicidal thoughts; the provider noted that it appeared that the above symptoms were triggered by traumatic events experienced during the Veteran’s military service rather than by childhood trauma and are having a significant effect on his overall level of functioning and on his vocational abilities. In a January 2020 correspondence, the Veteran reported that, during his VA examination, he reported to the examiner that he and his father had a strained relationship and he would spank him until he bled. The Veteran indicated that this was customary in his culture and only occurred during his elementary school age years due to his grades. The Veteran additionally notes that he reported to the VA examiner many other things related to the traumatic events that happened during his service, which the examiner completely ignored. The Veteran reported that his father was upset that the Veteran did not tell him he was joining the military but knew it would “make him a man.” He indicated that he did not have PTSD or depression prior to service, and he and his father have an amazing relationship now. The Veteran indicated that he reported a bar fight during service in September 1985, in which he was punched in the cheek and many times in the head; he indicated that he suffered a nose injury while playing football in September 1985; he further indicated that he described the event in which he was held underwater by his water safety survival instructor; he reported an incident in which he was hit in the nose and forehead with a metal pole while setting up tents in approximately April to June 1986; he further indicated that he spoke of the events noted above, in which a vehicle in his convoy hit an unarmed man, killing him; the event in which he was guarding the hospital during a field exercise full of dogs; and the event in which he witnessed two service members engaging in sexual acts. The Veteran referenced the November 2019 letter from his treating provider, which notes, in pertinent part, that the Veteran had combat related PTSD, and that his symptoms were triggered by traumatic events during his military service rather than by childhood trauma. The Veteran contends therefore, that the VA examiner’s opinions are not adequate, and his treating VA physician’s opinion should be afforded more probative weight. A letter from the Veteran’s treating physician, received in January 2020, but dated in January 2016, notes, in pertinent part, that the Veteran had a diagnosis of “PTSD (on further assessments was found to be combat-related)”. A DBQ, completed by the Veteran, was received in January 2020, which notes diagnoses of MDD, anxious distress, unspecified anxiety disorder, and PTSD. No other information was provided in this DBQ. A statement from the Veteran’s spouse, received in January 2020, indicates that she and the Veteran were married while he was in the military, and she witnessed firsthand the trauma he experienced. She indicated that after his discharge, he had nightmares, vivid memories, or flashbacks of the events. He felt emotionally cut off, numb, on guard, irritated, and jumpy; he had difficulty sleeping, trouble concentrating, and pulled away from others. The Veteran’s spouse indicated that in her opinion he suffered from a mental disability due to the trauma he suffered in the military. She described the events in which the Veteran was involved in the field exercise protecting the hospital, indicating that the Veteran had to help carry the dead dogs to the dumpster; she additionally noted the water safety training, in which the Veteran was held under water to the point of drowning for 12 weeks; the incident in which his convoy hit a man and killed him, as well as the incident in which the Veteran witnessed the two service-members engaging in sexual acts and the Veteran’s subsequent testimony against them, further indicating that the Veteran was “bullied and tortured by the other military men for ratting them out.” She also noted the incident in which the Veteran was instructed to throw trash into the ocean. Finally, she reported an incident in which the Veteran witnessed higher ranking service-members carry a drunk female service-member onto a beach and rape her. She indicated that the Veteran was also hit in the nose with a metal pole in Korea and told to wait until he returned stateside for surgery, which was not performed properly. At his November 2020 Board hearing the Veteran reported that, in 1987, a bunch of fellow servicemembers raped a girl. From that point on, everything started, and this was back in 1986 or 1987. Since then, the Veteran indicated that he was depressed and anxious because he was not able to do or say anything about what he saw. Also, at his first duty station in Japan, the Veteran indicated that he witnessed two servicemembers performing oral sex, and he had to testify against him. He indicated that this occurred within the first couple weeks of arriving, and he was bullied the entire year. The Veteran indicated from that point on, he was afraid to say anything about what he saw. He indicated that this resulted in feelings of depression, and anxiety, and he wanted to kill himself. He reported that he talked to a priest in Camp Lejeune. The Veteran’s spouse reiterated that, after he reported and testified against the servicemembers, he was tortured. From that point, despite what he witnessed, he did not say anything, and it continues to bother him. She indicated that it is on his mind constantly; he also had nightmares during service. Moreover, regarding secondary service connection, the Veteran reported that his varicose veins were embarrassing, and people would stare at his legs. He indicated that this causes him anxiety and depression because he always has to cover his legs. After a review of the evidence, the Board finds that the evidence is at least in relative equipoise as to whether the Veteran’s acquired psychiatric disorder is causally related to his active service. As an initial matter, the Board notes that the Veteran has been diagnosed with different psychiatric disorders, including PTSD, MDD, and unspecified anxiety disorder, and that a grant of service connection for an acquired psychiatric disorder incorporates all such psychiatric symptomatology reported by the Veteran. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); Mittleider v. West, 11 Vet. App. 181, 182 (1998). Although the evidence suggests that the Veteran may have experienced some symptoms of depression and anxiety prior to service, the presumption of soundness is applicable in this case. Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). Specifically, despite the Veteran’s medical treatment records suggesting that the Veteran reported experiencing psychiatric symptoms prior to his active service, his entrance examination does not note any psychiatric disorder, and his lay reports alone are insufficient to rebut the presumption of soundness by the high evidentiary burden of clear and unmistakable evidence that his psychiatric disorder pre-existed service. Regarding an in-service event, illness, or injury, the Veteran and his spouse have consistently reported psychiatric symptoms stemming from one or more traumatic events in service. Military personnel records are, unfortunately, mostly illegible. However, his DD 214 reflects that his military occupational specialty (MOS) included motor vehicle operator, with 11 months and 14 days of foreign service during his first period of active service and service in Desert Storm in February 1991. The Veteran has reported numerous events during his service which resulted in feelings of depression and distress. These events have been corroborated by written statements and testimony supplied by the Veteran’s spouse, who was married to him at the time. Lay statements from the Veteran’s spouse and other family members indicate that since separation from service, the Veteran experienced symptoms including depression, irritability, hypervigilance, anxiety, social isolation, and sleep impairment. This further strengthens the Veteran’s assertions regarding experiencing psychiatric symptoms due his experience in service. Finally, the evidence of record plausibly suggests a nexus between the Veteran’s acquired psychiatric disorder and military service. Specifically, each mental health clinician opined that the Veteran’s psychiatric disorder is related to military service. This is echoed by the lay statements indicating that events in service caused the Veteran a great deal of mental distress with continuous symptoms since. He identified symptoms that are readily attributable to psychiatric disorders, including depression, anxiety, chronic sleep impairment, and isolation. Based on the above, the Board finds that the medical evidence is, at least, in equipoise as to whether the Veteran’s acquired psychiatric disorder was caused by or otherwise etiologically related to his active military service. Therefore, resolving reasonable doubt in the Veteran’s favor, service connection for an acquired psychiatric disorder is warranted. As the Board is granting the claim on a direct theory of entitlement, no discussion of whether service connection is warranted on a separate theory is necessary, to include a discussion of whether the Veteran’s acquired psychiatric disorder is proximately due to or a result of his service-connected disabilities. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Entitlement to an evaluation in excess of 10 percent prior to May 23, 2019, and an evaluation in excess of 20 percent thereafter, for varicose veins of the bilateral lower extremities is granted. The Veteran’s varicose veins are currently rated as 10 percent disabling prior to May 23, 2019, and 20 percent disabling thereafter, under Diagnostic Code 7120 for varicose veins. The Veteran contends that a higher rating is warranted for each lower extremity varicose veins because he has experienced symptoms of persistent edema, hardening, and discoloration throughout the period on appeal. Diagnostic Code (DC) 7120 provides a 10 percent rating for varicose veins with intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery. A 20 percent rating for persistent edema which is not completely relieved by elevation of the extremity, whether or not there is beginning stasis pigmentation or eczema. A 40 percent rating is assigned when varicose veins cause persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration. A 60 percent evaluation is assigned when there is evidence of persistent edema or subcutaneous induration, stasis pigmentation or eczema, and persistent ulceration. A 100 percent evaluation is assigned for massive board-like edema with constant pain at rest. 38 C.F.R. § 4.104. A September 2015 VA examination notes a diagnosis of bilateral varicose veins, with aching and fatigue in the bilateral legs after prolonged standing or walking, which was not relieved with elevation or compression hosiery; no edema, stasis pigmentation, or other symptoms or related diagnoses were noted. The impact of the Veteran’s varicose veins on his ability to work was difficulty standing and walking for long periods during flare-ups. An August 2016 VA examination notes a diagnosis of bilateral varicose veins. The Veteran reported that he had chronic pain, burning, tingling, and numbness while walking and running, and his pain is described as a burning sensation exacerbation of symptoms while lying down. No additional care or treatment has been required. The examination notes symptoms of aching and fatigue in the bilateral legs with prolonged standing and walking. No other pertinent physical findings, complications, conditions, signs or symptoms were noted. The examiner indicated that the Veteran’s bilateral varicose veins did not impact his ability to work. A November 2016 medical treatment record notes that the Veteran had varicose veins for more than 30 years, without a history of open wounds. He complained of itching, burning, and cramping. He also reported that his legs become hot. He reported that neither the calf-high nor thigh-high stockings work. He reported that surgery to collapse the veins was recommended, but he decided not to proceed; he indicated that he has not worn stockings since surgery was recommended approximately 5 years ago. A December 2016 statement from the Veteran indicates that he experienced itching, burning, and swelling due to his varicose veins every day. Walking had become a problem. He indicated that his varicose veins have been “extremely severe” the last few years. An October 2017 VA treatment record notes that the Veteran reported that he attempted using compression stockings for years, but they have not abated his symptoms. He complained of itching and pain with the varicose veins but denied a history of ulcers. Examination revealed bilateral lower extremities with varicose veins present, more significant over the right calf, compared to left; no presence of ulcers; there was mild discoloration of skin at bilateral ankles. A May 2019 VA examination notes that the Veteran had varicose veins of the bilateral lower extremities. The examination notes that the Veteran had asymptomatic palpable and visibile varicose veins bilaterally, resulting in aching and fatigue with prolonged walking, and the symptoms were relieved by elevation of the extremity. The examination further notes bilateral beginning stasis pigmentation, bilateral persistent edema, and persistent bilateral subcutaneus induration. Due to his varicose veins, the Veteran lower leg pain, tingling, numbness, and difficulty with prolonged walking more than a quarter mile, impacting his ability to work. An August 2019 VA treatment record notes that the Veteran reported burning, itching, numbing and aching. He reported using high knee stockings for approximately three to six months. The record notes varicosities more prominent, minimal edema, and no stasis changes. At his November 2020 Board hearing, the Veteran reported that he has experienced numbness, itching, and burning sensation. He additionally noticed different colors on his veins and pain at night and when walking. He reported that his whole leg and ankles swell up, and he noticed discoloration of the skin around the veins in the ankles all the way up his legs; additionally, the skin is hardened on the legs. He reported that the swelling was present “way before 2013”. The Veteran’s spouse also testified that the Veteran’s veins bulge, his legs were painful, and his ankles would swell. At night, he had to elevate his legs to keep the swelling from being too severe. She additionally noticed discoloration and hardening. The Veteran’s spouse indicated that most of his symptoms started approximately 10 to 15 years prior and the hardening started approximately six years prior. After a review of the evidence, the Board finds the Veteran’s right and left lower extremity varicose veins symptoms more nearly approximate the symptoms considered by a 40 percent disability rating throughout the period on appeal. Specifically, the Veteran and his spouse have competently and credibly reported that the Veteran has experienced symptoms of pain, daily swelling, alleviated by elevating his legs nightly, discoloration of the skin surrounding his veins around the ankles, and hardening of the skin. Layno v. Brown, 6 Vet. App. 465, 471 (1994). Based on these symptoms of pain, persistent edema, and stasis pigmentation, the Board resolves reasonable doubt in favor of the Veteran and finds that a 40 percent rating is warranted throughout the appellate period under Diagnostic Code 7120. A 60 percent rating is not available because Diagnostic Code 7120 requires that there be persistent ulceration. The medical evidence consistently notes that the Veteran did not have ulcerations or open wounds at any time during the period on appeal, and the Veteran does not contend otherwise. Similarly, although the Veteran and his spouse have reported some hardening of the skin, the evidence does not reflect, and the Veteran does not contend, that he had massive board-like edema at any time during the period on appeal. Thus, the Board does not find that his reports of hardening more closely approximates a disability picture associated with massive board-like edema. Thus, a rating in excess of 40 percent is not warranted at any time during the period on appeal. 38 C.F.R. § 4.104, Diagnostic Code 7120. The Board has considered rating the Veteran’s varicose veins of the bilateral lower extremities under other Diagnostic Codes, in order to provide him with the most beneficial rating. However, as the criteria in Diagnostic Code 7120 most accurately describes the symptoms associated with the service-connected bilateral lower extremity varicose veins, the Board finds that is the most appropriate Diagnostic Code under which to rate the Veteran’s disability. REASONS FOR REMAND Entitlement to service connection for sleep apnea, to include on a secondary basis, is remanded. The Veteran contends that service connection is warranted for his sleep apnea on both a direct and secondary basis. Specifically, he asserts that his sleeping problems and snoring started during active service after he incurred an injury to his nose. Alternatively, the Veteran contends that his sleep apnea is due to his service-connected deviated septum. STRs are silent for complaints, treatment, or diagnosis related to any sleep disorder, although records in September 1985 and September 1986 note reports of difficulty breathing, and an October 1987 record notes that the Veteran underwent nasal surgery in February 1987. His August 1988 separation examination notes nasal symptoms but is absent any treatment or diagnosis for a sleep disorder. Medical records reflect that the Veteran underwent a sleep study in December 2011; he presented with symptoms of loud snoring, witnessed apneas, excessive daytime somnolence, nonrestorative sleep, morning headaches, difficulty falling asleep, racing thoughts at night, excessive sweating, waking gasping for air, waking feeling sleepy, and loss of sex drive. A March 2013 medical record notes a diagnosis of sleep apnea with hypersomnia. A July 2014 medical treatment record notes that the Veteran reporting sleeping difficulty, with gradual onset with a persistent pattern for years. A statement from the Veteran’s treating physician notes that the Veteran was diagnosed with sleep apnea caused by his deviated septum, but no rationale was provided. A September 2015 VA DBQ notes a diagnosis of obstructive sleep apnea. The Veteran reported that his sleep problems began in 1985. He indicated that he had a deviated septum and he was diagnosed as having sleep apnea in 2012. The examiner opined that the Veteran’s sleep apnea was less likely than not proximately due to or the result of his deviated septum. The examiner reasoned that the Veteran experienced a nasal bone trauma in October 1985, and STRs note a diagnosis of deviated septum in September 1986; however, there were no records noting sleep apnea during service. His sleep apnea was diagnosed in 2012 per the Veteran, and he separated from service in 1992. The etiology of sleep apnea is multifactorial, and the risk factors are as follows: the most important risk factor is obesity. It is two to three times more likely in males than females. Craniofacial and upper airway abnormalities increase the likelihood of having or developing sleep apnea. Nasal congestion and smoking also increases the risk. Thus, based on the lack of evidence to support the claim, sleep apnea is less likely than not related to the deviated septum. No direct service connection opinion was provided, and although the examiner listed risk factors as a rationale for the Veteran’s sleep apnea etiology, the examiner did not explain which of these risk factors applied specifically to the Veteran’s case. An October 2015 correspondence from the Veteran indicates that he suffered an injury to his face and nose during his deployment in 1985 or 1986, and he was unable to breath normally from that time. He reported that he started to use nose drops and snore loudly. He reported that when he returned stateside, he went to sick call and was told that he had a deviated septum, which required surgical repair. He underwent surgery in 1986, and for 20 or more years, he had been using nose drops for sleeping, snoring, and breathing. A September 2016 statement from the Veteran’s treating ENT notes that the Veteran had obstructive sleep apnea. Upon review of the Veteran’s VA medical records and history of traumatic deviated nasal septum in service, the provider indicated that it is more likely than not that the Veteran’s deviated nasal septum contributed to his sleep apnea. Although this opinion appears to suggest aggravation of the Veteran’s sleep apnea by his service-connected deviated septum, no rationale was provided. A July 2017 VA examination notes a diagnosis of obstructive sleep apnea. The examination notes that the Veteran was diagnosed with sleep apnea in 2011, which he attributes to his stable nasal deviated septum from an injury sustained in Korea and a subsequent surgery to repair his deviated septum. The examiner opined that it was less likely than not that the Veteran’s sleep apnea was due to or the result of his deviated septum. The examiner reasoned that the Veteran was diagnosed with sleep apnea in 2011 and his treating physician attributes to his repaired nasal deviated septum from an injury sustained in Korea; however, the physician failed give a basis for the sleep apnea considering that the Veteran was diagnosed with sleep apnea prior to meeting the Veteran in January 2012 and the Veteran had previously had his deviated septum repaired. Further the Veteran was diagnosed with sleep apnea in 2011, more than 23 years post deviated septum incidence and after the Veteran gained a tremendous amount of weight, becoming morbidly obese with a BMI of 48.0, which is considered by the CDC national guidelines as morbidly obese and the leading cause of sleep apnea. Literature supports symptoms of sleep apnea include loud snoring, morning headaches, fatigue and daytime sleepiness. Sleep apnea is due to obstruction of airway during sleep. There are several risk factors to include obesity, narrow airway, and genetic predisposition. The important risk factors for obstructive sleep apnea are advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities. Additional risk factors identified in some studies include smoking, nasal congestion, and family history. The prevalence of obstructive sleep apnea increases from young adulthood through the sixth to seventh decade. Sleep apnea is approximately two to three times more common in males than females. In both males and females, the strongest risk factor for sleep apnea is obesity. People who are obese have four times the risk of sleep apnea. The medical records document diagnosis of morbid obesity with BMI exceeding 40. The Veteran was also diagnosed with nonservice-related residuals of cerebral spinal fluid shunt due to excess fluid and CSF otorrhea. Therefore, it is less likely as not that the Veteran’s sleep apnea is proximately caused by or related to his deviated septum. The July 2017 VA examiner did not provide a direct service connection opinion. Additionally, although the examiner considered the Veteran’s medical records and the opinion from the private provider, the Board notes that the examiner, in finding that the Veteran’s sleep apnea was more likely related to his obesity because he did not receive a diagnosis for sleep apnea until more than 20 years after separation from service, did not address the Veteran’s reported problems breathing and snoring since his nasal injury in service. Moreover, it is unclear what relevance the Veteran’s “residuals of cerebral spinal fluid shunt due to excess fluid and CSF otorrhea”, had on the examiner’s opinion. Furthermore, the Board notes that VA’s acting general counsel has found that obesity may act as an “intermediate step” between a service-connected disability and a disability for which secondary service connection is sought under 38 C.F.R. § 3.310(a). See VAOPGCPREC 1-2017 (Jan. 6, 2017). Thus, while the July 2017 VA examiner found that the Veteran’s sleep apnea was due to obesity, that does not preclude the possibility that service connection for sleep apnea can be service connected as secondary to the service-connected deviated septum, with obesity serving as an “intermediary step” as described in the January 2017 acting general counsel’s opinion. A statement from the Veteran’s spouse, dated in November 2019, notes that, during service, the Veteran told her that he was having problems breathing, resulting in a septoplasty. She reported that she visited him at Camp Lejeune after his surgery and she noticed that he started snoring loudly. Additionally, she reported that he seemed to stop breathing, choke, and gasp for air at night. She indicated that the Veteran did not snore before his injuries in Japan, and since his in-service surgery, he developed sleep apnea, difficulty breathing, difficulty sleeping, daytime sleepiness, and weight gain. At his November 2020 Board hearing, the Veteran reported snoring in service and gasping for air in his barracks, aggravating everyone else. He reported that his symptoms started after his in-service nose trauma because he was unable to breath. The Veteran’s spouse also testified that the Veteran never had problems before service; however, after surgery, he breathed through his mouth all the time, and he could not breath while he was sleeping, gasping for air. She additionally noted that sometimes it seemed like he was not even breathing, and his snoring was so bad that he started taking Afrin. A November 2020 statement from former fellow service-member who served with the Veteran in Japan notes that the Veteran snored often during service. It was so loud that his bunkmates tried to wake him. A November 2020 sleep apnea questionnaire, completed by the Veteran’ treating physician, notes that, after review of the July 2017 VA DBQ, the Veteran’s sleep apnea was as likely as not exacerbated beyond the natural progression by his deviated septum. The provider indicated that, despite the 23 year gap between the deviated septum and his 2011 diagnosis of sleep apnea, the deviated nasal septum was most likely what caused the snoring and sleep apnea, which was also supported by the lay statement from the fellow service member that snoring was present during his deployment from 1985 to 1987. Additionally, the provider indicated that, although his deviated septum was repaired, it has since re-deviated. The provider indicated that nasal trauma and the deviated septum caused obstructive breathing and increased snoring; his sleep apnea has made weight loss difficult due to poor sleep. The provider further noted, however, that without an updated sleep study, the provider was unable to determine the level of exacerbation of the sleep apnea beyond its baseline. The provider’s opinion here suggests that the Veteran’s sleep apnea was aggravated by his service-connected deviated septum; however, the rationale does not support this conclusion as it addresses causation. The Board finds that, in light of the competent and credible lay reports of the onset of the Veteran’s problems sleeping, snoring, and difficulty breathing during service and continuity of these symptoms since service, and since no medical opinion addressing direct service connection has been obtained, a remand for a medical opinion addressing direct service connection is necessary. Additionally, the Board finds that another medical opinion addressing secondary service connection is necessary. In this regard, the Board finds that opinions provided by the private provider and VA examiners, alone or in combination, do not suffice to place the matters in equipoise at this time. Therefore, given the deficiencies in these opinions, the Board finds that another medical opinion is necessary. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. The Veteran contends that he is unable to work as a result of his service-connected disabilities, particularly his headaches. In light of the Board’s decision to grant the Veteran’s claims for service connection, including for his headache disorder, herein, the Veteran’s pending appeal for a TDIU is inextricably intertwined with the initial ratings to be assigned for his service-connected headaches and acquired psychiatric disorder. As such, remand of the TDIU issue is warranted to allow the AOJ to rate the newly service-connected disabilities and then to readjudicate the TDIU issue. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran’s sleep apnea. The electronic claims file must be made accessible to the examiner for review in conjunction with the opinion. (a.) The examiner should opine as to whether it is it at least as likely as not (50 percent probability or more) that the Veteran’s sleep apnea was incurred in or caused by an event, injury, or disease during active service. The examiner should explain why or why not, specifically discussing the Veteran’s difficulty breathing noted in his STRs during active service and the lay evidence that he snored during and since service. (b.) The VA examiner should also opine as to whether the Veteran’s sleep apnea is at least as likely as not (50% probability or greater) caused or aggravated (increased in severity beyond the natural progress of the disorder) by his service-connected deviated septum, considering each individually (that is, whether it was caused, and whether it was aggravated) and providing adequate rationale on both points. The examiner should also specifically address the November 2020 private opinion. (c.) If aggravation is found, please attempt to quantify the degree of aggravation beyond the baseline level of disability. (d.) Finally, the examiner should opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s service-connected deviated septum caused him to become obese, specifically discussing the assertion that the deviated septum resulted in weight gain; and (e.) If the Veteran’s service-connected deviated septum caused him to become obese, the examiner should opine as to whether it is at least as likely as not that this obesity was a substantial factor in causing his sleep apnea. An explanation of all opinions expressed must be provided, with consideration given to all evidence of record. If the examiner cannot provide any of the requested opinions without resorting to speculation, he or she should indicate such and provide a supporting rationale as to why the opinion cannot be made without resorting to speculation. (Continued on the next page)   2. After completing the above development, and after assigning disability ratings for the Veteran’s service-connected headaches and acquired psychiatric disorder, readjudicate the issues remaining on appeal, including the issue of entitlement to a TDIU. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Hite, 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.