Citation Nr: 21004304 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 17-06 187 DATE: January 26, 2021 ORDER New and material evidence has been received and the claim for service connection for diabetes mellitus type II, to include as due to exposure to certain herbicides is reopened. New and material evidence has been received and the claim for service connection for diabetic right eye retinopathy to include as secondary to diabetes is reopened. New and material evidence has been received and the claim for service connection for diabetic left eye retinopathy to include as secondary to diabetes is reopened. New and material evidence has been received and the claim for service connection for diabetic nephropathy to include as secondary to diabetes is reopened New and material evidence has been received and the claim for service connection for diabetic ketoacidosis to include as secondary to diabetes is reopened New and material evidence has been received and the claim for service connection for diabetic peripheral neuropathy of the right upper extremity to include as secondary to diabetes is reopened. New and material evidence has been received and the claim for service connection for diabetic peripheral neuropathy of the left upper extremity to include as secondary to diabetes is reopened New and material evidence has been received and the claim for service connection for diabetic peripheral neuropathy of the right lower extremity to include as secondary to diabetes is reopened New and material evidence has been received and the claim for service connection for diabetic peripheral neuropathy of the left lower extremity to include as secondary to diabetes is reopened New and material evidence has been received and the claim for service connection for erectile dysfunction to include as secondary to diabetes is reopened. New and material evidence has been received and the claim for service connection for left Charcot foot to include as secondary to diabetes is reopened. New and material evidence has been received and the claim for service connection for diabetic gastroparesis to include as secondary to diabetes is reopened. New and material evidence has been received and the claim for service connection for residuals of a kidney transplant as secondary to diabetes is reopened. New and material evidence has been received and the claim for service connection for hypertension to include as due to exposure to certain herbicides is reopened. New and material evidence has been received and the claim for service connection for a heart disability, identified as coronary artery disease, to include as due to exposure to certain herbicides is reopened. New and material evidence has been received and the claim for service connection for balance issues to include as secondary to diabetes is reopened. New and material evidence has been received and the claim for service connection for excessive sweating to include as secondary to diabetes is reopened. New and material evidence has been received and the claim for service connection for chronic fatigue syndrome is reopened. New and material evidence has been received and the claim for service connection for internal scarring is reopened. New and material evidence has been received and the claim for service connection for depression is reopened. Entitlement to service connection for diabetes mellitus type II to include as due to exposure to certain herbicides is granted. Entitlement to service connection for right eye retinopathy to include as secondary to diabetes is granted. Entitlement to service connection for left eye retinopathy to include as secondary to diabetes is granted. Entitlement to service connection service connection for diabetic nephropathy to include as secondary to diabetes is granted. Entitlement to service connection for diabetic ketoacidosis to include as secondary to diabetes is granted. Entitlement to service connection for diabetic peripheral neuropathy of the right upper extremity to include as secondary to diabetes is granted. Entitlement to service connection for diabetic peripheral neuropathy of the left upper extremity to include as secondary to diabetes is granted. Entitlement to service connection for diabetic peripheral neuropathy of the right lower extremity to include as secondary to diabetes is granted. Entitlement to service connection for diabetic peripheral neuropathy of the left lower extremity to include as secondary to diabetes is granted. Entitlement to service connection for erectile dysfunction to include as secondary to diabetes is granted. Entitlement to service connection for left Charcot foot to include as secondary to diabetes is granted. Entitlement to service connection for diabetic gastroparesis to include as secondary to diabetes is granted Entitlement to service connection for residuals of a kidney transplant to include as secondary to diabetes is granted. Entitlement to service connection for hypertension to include as due to exposure to certain herbicides is granted. Entitlement to service connection for coronary artery disease to include as due to exposure to certain herbicides is granted. Entitlement to service connection for depression to include as secondary to service connected diabetes is granted. Entitlement to service connection for hypothyroidism to include as due to exposure to certain herbicides is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for elevated creatine is denied. Entitlement to service connection for hyperlipidemia is denied. Entitlement to service connection for bilateral hearing loss is denied. REMANDED Entitlement to a total disability rating due to individual unemployability is remanded. Entitlement to an increased rating in excess of 40 percent for a chronic duodenal ulcer with vagotomy bilateral Jaboulay, pyloroplasty and gastrostomy is remanded. Entitlement to an increased rating in excess of 10 percent for a post-operative surgical scar due to chronic duodenal ulcer is remanded. Entitlement to compensable rating for a superficial non-linear scar residual post-operative due to chronic doudenal ulcer is remanded. Entitlement to service connection for balance issues is remanded. Entitlement to service connection for excessive sweating is remanded. Entitlement to service connection for chronic fatigue syndrome is remanded. Entitlement to service connection for hyperkalemia is remanded. Entitlement to service connection for bronchitis is remanded. Entitlement to service connection for arteriovenous fistula is remanded Entitlement to service connection for a bilateral hand disability is remanded Entitlement to service connection for an enlarged lymph nodes in groin is remanded. Entitlement to service connection for anemia is remanded. Entitlement to service connection for bilateral foot onychomycosis is remanded. Entitlement to service connection for lung disability to include hypersensitive lung disease is remanded. Entitlement to service connection for rhabdomyolysis of the kidney is remanded. Entitlement to service connection for residuals of a bacterial infection secondary surgery to is remanded. Entitlement to service connection for internal scarring is remanded. Entitlement to service connection for bilateral foot ulcers is remanded. Entitlement to service connection for bilateral foot osteomyelitis is remanded. Entitlement to service connection for a right foot scar due to ulcer is remanded. FINDINGS OF FACT 1. In unappealed December 2002 and March 2006 rating decisions, the RO denied service connection for diabetes mellitus type II, bilateral retinopathy, diabetic nephropathy, ketoacidosis, bilateral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, residuals of a kidney transplant, hypertension, heart disability, balance issues, excessive sweating, chronic fatigue syndrome, internal scarring and depression based on a finding that there was insufficient evidence of a relationship between these disabilities and the Veteran’s service. 2. The evidence added to the record since the December 2002 and March 2006 rating decisions, when viewed by itself or in the context of the entire record, relates to an unestablished fact that is necessary to substantiate the claims of service connection for service connection for diabetes mellitus type II, bilateral retinopathy, diabetic nephropathy, ketoacidosis, bilateral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, residuals of a kidney transplant, hypertension, heart disability, balance issues, excessive sweating, chronic fatigue syndrome, internal scarring, and depression. 3. The Veteran’s service included travel along the perimeter at the U.S. Air Force at the Royal Thai Air Base in U-Tapao, Thailand, during the Vietnam Era, to include April 1972 to August 1972, as an Administrative Specialist, and the Veteran had a diagnosis of diabetes mellitus type II, coronary artery disease, and hypothyroidism. 4. The Veteran’s bilateral retinopathy, diabetic nephropathy, diabetic ketoacidosis, bilateral upper and lower extremities peripheral neuropathy, erectile dysfunction, left Charcot foot, diabetic gastroparesis, and residuals of a kidney transplant were related to his diabetes mellitus type II. 5. Elevated creatine and hyperlipidemia are laboratory findings and not disabilities for which service connection may be granted. 6. The Veteran's hypertension was at least as likely as not related to exposure to certain herbicides. 7. There is no evidence that the Veteran had hearing loss which met VA requirements to be considered a disability. 8. Tinnitus is etiologically related to acoustic trauma sustained in active service. 9. The Veteran’s depression was related to his diabetes mellitus type II. CONCLUSIONS OF LAW 1. The December 2002 and March 2006 rating decisions which denied service connection for diabetes mellitus type II, bilateral retinopathy, diabetic nephropathy, ketoacidosis, bilateral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, residuals of a kidney transplant, hypertension, heart disability, balance issues, excessive sweating, chronic fatigue syndrome, internal scarring, and depression, are final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), 3.160(d), 20.200, 20.302, 20.1103. 2. With respect to the claims for service connection for diabetes mellitus type II, bilateral retinopathy, diabetic nephropathy, ketoacidosis, bilateral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, kidney transplant, hypertension, heart disability, balance issues, excessive sweating, chronic fatigue syndrome, internal scarring, and depression, new and material evidence has been received since the December 2002 and March 2006 denials. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for entitlement to service connection for diabetes mellitus type II, coronary artery disease, and hypothyroidism as secondary to exposure to certain herbicides have been met. 38 U.S.C. §§ 1110, 1116(a)(2) 5107; 38 C.F.R. §§ 3.303 (a)(b), 3.307(b), 3.309(e). 4. The criteria for service connection on a secondary basis for bilateral retinopathy, diabetic nephropathy, diabetic ketoacidosis, bilateral upper and lower extremities peripheral neuropathy, erectile dysfunction, left Charcot foot, diabetic gastroparesis, and residuals of a kidney transplant are met. 38 U.S.C. §§ 1110, 1131, 5107, 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 5. The criteria to establish service connection for elevated creatine and hyperlipidemia are not met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 6. The criteria for entitlement to service connection for hypertension to include as secondary to exposure to certain herbicides (Agent Orange) have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. 7. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107, 5121; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.385. 8. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 5107(b), 5121; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for service connection on a secondary basis for depression have been met. 38 U.S.C. §§ 1110, 5107, 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from October 1968 to September 1972. The Veteran died in September 2018. As an initial matter, the Board expresses its sympathy to the Appellant for the loss of her husband and recognizes the years of excellent service he provided to the country during his service in the United States Air Force. New and Material Evidence Initially, the Board notes that whenever a claim to reopen is filed, regardless of how it was characterized by the agency of original jurisdiction, the Board must make a de novo determination as to whether new and material evidence has been received. Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996) (whether new and material evidence has been submitted must be asked and answered by the Board de novo whenever a claim to reopen is filed). New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For the purpose of establishing whether new and material evidence has been submitted, the credibility of evidence is presumed unless the evidence is inherently incredible or consists of statements that are beyond the competence of the person or persons making them. Justus v. Principi, 3 Vet. App. 510, 513 (1992); Meyer v. Brown, 9 Vet. App. 425, 429 (1996); King v. Brown, 5 Vet. App. 19, 21 (1993). 1. Whether new and material evidence has been received to reopen the service connection claims for diabetes mellitus type II, bilateral retinopathy, diabetic nephropathy, ketoacidosis, bilateral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, residuals of a kidney transplant, hypertension, heart disability, balance issues, excessive sweating, chronic fatigue syndrome, internal scarring and depression. The Veteran was denied service connection for diabetes mellitus type II, bilateral retinopathy, diabetic nephropathy, ketoacidosis, bilateral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, residuals of a kidney transplant, hypertension, a heart disability, balance issues, excessive sweating, chronic fatigue syndrome, internal scarring, and depression in a December 2002 and March 2006 rating decisions because there was insufficient evidence that the Veteran’s disabilities were related to his active service. 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, 117 (2010). In determining whether this 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 the VA’s duty to assist or through consideration of an alternative theory of entitlement. 38 C.F.R. § 3.156(a); Shade v. Shinseki, supra. The Appellant’s testimony in July 2020 that the Veteran’s diabetes is related to exposure to certain herbicides when he was stationed in Thailand on active duty is new in that it was not previously of record. Moreover, the Appellant’s testimony that bilateral retinopathy, diabetic nephropathy, ketoacidosis, bilateral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, kidney transplant, hypertension, heart disability, balance issues, excessive sweating, chronic fatigue syndrome, internal scarring, and depression are related to diabetes is also new. This testimony is material because it relates to unestablished facts necessary to substantiate the Appellant’s claims. Specifically, due to the prior lack of evidence showing a relationship between the Veteran’s disabilities and his active duty service, this new evidence is material because it relates to an element that was previously not shown, a nexus. See Shade, supra. Accordingly, the Board finds that new and material evidence has been submitted, and the claims for service connection for diabetes mellitus type II, bilateral retinopathy, diabetic nephropathy, ketoacidosis, bilateral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, residuals of a kidney transplant, hypertension, a heart disability, balance issues, excessive sweating, chronic fatigue syndrome, internal scarring, and depression are reopened. 38 U.S.C. § 5108 Service Connection A veteran who, during active military service, served in the Republic of Vietnam during the Vietnam era (beginning in January 1962 and ending in May 1975) shall be presumed to have been exposed during such service to herbicide agents, including the herbicide commonly referred to as Agent Orange. 38 U.S.C. § 1116 (a)(3); 38 C.F.R. §§ 3.307, 3.309. Significantly, however, there have been important changes in the information surrounding the use of herbicides in Thailand. The evidence of this was found in a declassified Vietnam era Department of Defense (DOD) document titled Project CHECO Southeast Asia Report: Base Defense in Thailand. Therefore, based on this report, the Board finds that consideration must be made from the evidence as to whether a veteran's service activities involved duty on or near the perimeter of the military base where the Veteran was stationed. Specifically, the report observes that some evidence that the herbicides used on the Thailand base perimeters may have been either tactical, procured from the Republic of Vietnam, or a commercial variant of much greater strength and with the characteristics of tactical herbicides. Therefore, special consideration of herbicide exposure cases should be extended to those Veterans whose duties placed them on or near the perimeters of Thailand military bases. This allows for presumptive service connection of the diseases associated with herbicide exposure. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b). 2. Entitlement to service connection for diabetes mellitus type II, coronary artery disease, and hypothyroidism to include as due to exposure to certain herbicides. At the onset, the Board acknowledges that there is no dispute that the Veteran was diagnosed with diabetes mellitus type II, as referenced in a June 2018 VA treatment note. Further, the record shows that the Veteran had diagnoses of hypothyroidism and coronary artery disease. Likewise, there is no dispute that the Veteran was station at U-Tapao, Thailand, during the Vietnam Era, to include from April 1972 to August 1972 as these dates are lifted from the Veteran’s corresponding service treatment records. Thus, the only question that remains is whether his service in Thailand warrants the presumption of exposure to herbicides. On this issue, the Board acknowledges that the Veteran did not serve in a position which VA has conceded as being exposed to herbicides on the base; however, the Board finds that the Appellant’s July 2020 testimony coupled with the Veteran’s December 2013 correspondence that he would travel to the perimeter as part of his regular comings and goings at the base to be credible evidence of his being near the perimeter. Therefore, the Board finds that based on the Appellant’s July 2020 testimony and the Veteran’s December 2013 competent and credible lay statement regarding his travel around the perimeter of the U-Tapao Royal Thailand Air Base meets the criteria for presumption of exposure to an herbicide agent during active military service in Thailand. Given that diabetes mellitus type II, coronary artery disease, and hypothyroidism are diseases that are presumed related to herbicide exposure, service connection is warranted on this basis. 38 C.F.R. §§ 3.307, 3.309(e); National Defense Authorization Act, Section 1090B, December 2020 (adding hypothyroidism, bladder cancer, and parkinsonism, to the list of presumptive diseases based on herbicide exposure). Accordingly, these claims are granted. Secondary Service Connection Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310 (b); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. 3. Entitlement to service connection for bilateral retinopathy, diabetic nephropathy, diabetic ketoacidosis, bilateral peripheral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, and residuals of a kidney transplant to include as secondary to diabetes mellitus type II. The Veteran is now service connected for diabetes mellitus type II per this decision. The Board now turns to the disabilities that are secondary to his now service-connected diabetes. The Board notes that the evidence of record shows that the Veteran had these current disabilities and that they were attributed to his diabetes mellitus type II. See bilateral retinopathy as noted in a March 2017 VA treatment record; diabetic nephropathy as noted in a March 2005 VA treatment record; diabetic ketoacidosis as noted in a July 1981 private treatment record; bilateral diabetic peripheral neuropathy of the upper and lower extremities as noted in a May 2014 private examination; erectile dysfunction; left Charcot foot as noted in a November 2012 private treatment record; diabetic gastroparesis as noted in a January 2005 private treatment note; and had a kidney transplant as noted in a July 2018 VA treatment note. As such, the Board finds that service connection is warranted for bilateral retinopathy, diabetic nephropathy, diabetic ketoacidosis, bilateral peripheral neuropathy of the upper and lower extremities, erectile dysfunction, left Charcot foot, diabetic gastroparesis, and residuals of a kidney transplant to include as secondary to diabetes. See 38 C.F.R. § 3.310(b); Allen v. Brown, supra. 4. Entitlement to service connection for elevated creatine and hyperlipidemia. The Appellant contends that the Veteran had elevated creatine and hyperlipidemia which were associated with his active service or service connected disabilities. While the record reflects that the Veteran had elevated creatine and hyperlipidemia, these findings are not a “disability” for the purposes of awarding VA disability benefits. 38 U.S.C. § 1701 (1); Allen v. Brown, 7 Vet. App. 439, 444-45 (1995) (applying definition of disability in section 1701(1) to statutes describing “eligibility for disability compensation for service-connected disabilities”). Instead, elevated creatine and hyperlipidemia are laboratory findings, not a disease or injury, or a disability resulting from a disease or injury. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (providing that diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are not, in and of themselves, disabilities) The term “disability” as used for VA purposes refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. at 439. In this case, there is no evidence of record suggesting that elevated creatine and hyperlipidemia, on its own, has caused any impairment of earning capacity or other disease or injury for which service connection may be granted. Lacking a current disability, service connection may not be granted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, service connection for elevated creatine and hyperlipidemia is denied. 5. Entitlement to service connection for hypertension to include as secondary to exposure to certain herbicides. The Appellant contends that the Veteran’s hypertension was related to his military service. While the Veteran was not diagnosed with hypertension during service, the most recent June 2018 VA treatment record confirmed a diagnosis of hypertension. On the issue of in-service incurrence, the Board notes that this issue was addressed above, and the Board has found that the Veteran is presumed to been exposed to certain herbicides. As such, VA laws and regulations provide that if a Veteran was exposed to certain herbicides during service, certain listed diseases are presumptively service connected. 38 U.S.C. § 1116 (a)(1); 38 C.F.R. § 3.309(e). 38 C.F.R. § 3.309(e) lists the diseases covered by the regulation. The Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Notice, 59 Fed. Reg. 341-46 (1994); Notice, 61 Fed. Reg. 41, 442-49 (1996); Notice, 72 Fed. Reg. 32, 395-32, 407 (Jun. 12, 2007); Notice, 74 Fed. Reg. 21,258-21, 260 (May 7, 2009); Notice, 75 Fed. Reg. 32540 (June 8, 2010). The Board notes that 38 C.F.R. § 3.309(e) specifically lists those diseases covered by the provision, and the list does not include hypertension. Thus, hypertension cannot be service connected on a presumptive basis. However, service connection can be established on a direct basis if a nexus can be shown. On November 15, 2018, the National Academies of Sciences, Engineering, and Medicine moved hypertension to the category of “sufficient” evidence of an association from its previous classification in the “limited or suggestive” category,” indicating that there is enough epidemiologic evidence to conclude that there is a positive association between hypertension and exposure to herbicides, including Agent Orange. See Hypertension Upgraded in Latest Biennial Review of Research on Health Problems in Veterans That May Be Linked to Agent Orange Exposure During Vietnam War (Nov. 15, 2018), http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=25137 (last visited Nov. 20, 2018). Based on this new finding, the Board finds that there is sufficient scientific evidence to etiologically link the Veteran’s hypertension to his presumed exposure to herbicides. As such, the Board has found that all elements of service connection for hypertension are met, and service connection is warranted 6. Entitlement to service connection for bilateral hearing. With regard to the Appellant’s contention that the Veteran’s bilateral hearing loss, should be service connected. The Board notes that there is no evidence that the Veteran’s hearing loss symptoms manifested sufficiently to meet the objective criteria for a hearing loss disability set out in 38 C.F.R. § 3.385. (For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent). The Veteran’s September 2013 VA examination does not indicate that the Veteran’s hearing loss met any of these requirements. The Board recognizes the Appellant’s contentions that the Veteran had symptoms of hearing loss, but there is no evidence in the claims file that he met the requirements under 38 C.F.R. § 3.385 listed above for impaired hearing loss to be recognized at a disability under VA purposes. Unfortunately, as a result, the Board must find that the Appellant has failed the first prong of the three-prong test for service connection for the claim for bilateral hearing loss, as there is no disability for VA purposes. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (there can be no valid claim for service connection in the absence of a present disability). Accordingly, the preponderance of the evidence is against the Appellant’s claim and entitlement to service connection for bilateral hearing loss is denied. 7. Entitlement to service connection for tinnitus. The Appellant has asserted that the Veteran’s tinnitus was a result of acoustic trauma sustained while in active service. Specifically, the Appellant has reported the Veteran had acoustic trauma in the form of proximity to the flight line. A review of the Veteran’s military personnel records shows that while in active service the Veteran was stationed at an active airbase. Therefore, the Board concedes the Veteran’s exposure to acoustic trauma while in active service. A review of the service medical records is silent for treatment for or a diagnosis of tinnitus while the Veteran was in active service. However, the Appellant has reported that the Veteran confided in her that he first experienced tinnitus while in active service and continued to experience tinnitus since his separation from active service. The Veteran is competent to report when he first experienced tinnitus and that the symptoms have continued since service. Heuer v. Brown, 7 Vet. App. 379 (1995); Falzone v. Brown, 8 Vet. App. 398 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Moreover, the Board finds the Veteran to be credible. The Board notes that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Veteran is competent to identify tinnitus and his statements have been found credible. In sum, the Board has conceded acoustic trauma during active service. The Appellant has competently reported that the Veteran first experienced tinnitus while in active service and continued to experience it since that time and those statements have been found credible by the Board. Accordingly, the Board finds that entitlement to service connection for tinnitus is warranted and the claim is granted. Entitlement to service connection for depression secondary to diabetes There is no dispute that the Veteran had a diagnosis of major depressive disorder as noted in a March 2018 VA treatment note. Likewise, the Veteran’s diabetes has been service connected per this decision. Thus, the only remaining element for service connection is a nexus between the Veteran’s depression and his diabetes. On the matter of nexus, the Board finds that the April 2017 VA treatment record links the Veteran’s depression to his chronic illnesses, to include diabetes and the medical instability that this disability has caused. The Board finds that the April 2017 clinician’s opinion is probative as he provided his analysis in the course of treating the Veteran. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, the Veteran was never provided a VA examination to address this contention and thus this opinion is the only opinion of record. Considering the foregoing, the Board finds that the Veteran’s depression was caused by his service connected diabetes, and thus service connection for depression is granted. REASONS FOR REMAND 1. Entitlement to a total disability rating due to individual unemployability. The development requested in connection with the foregoing claims could have bearing on whether an award of TDIU is proper. Hence, this final issue is not yet ripe for appellate review and must be deferred pending readjudication of those other remanded claims. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (noting that two or more issues are inextricably intertwined if the disposition of one claim could have a significant impact on the outcome of another). 2. Entitlement to an increased rating in excess of 40 percent for a chronic duodenal ulcer with vagotomy bilateral Jaboulay, pyloroplasty and gastrostomy, an increased rating in excess of 10 percent for a post operative surgical scar due to chronic duodenal ulcer, and an a compensable rating for a superficial non-linear scar residual post-operative due to chronic doudenal ulcer. The appellant in an October 2020 correspondence to VA wrote: “[a]dditional medical records were submitted at the South Carolina SC 29209 in hopes of a review. I also listed medical concerns on the MyHealthy Vet website in hopes that the doctors would read for the proper medication and requests for medical care.” As the Appellant indicated that she had submitted additional medical evidence to her local VA regional office which has not yet be associated with the claims file, The Board has determined that before adjudication can proceed the VA should ensure that this evidence has been appropriately collected and associated with the claims file. 3. Entitlement to service connection for balance issues, excessive sweating, chronic fatigue syndrome, internal scarring, hyperkalemia, bronchitis, arteriovenous fistula, bilateral hand disability, enlarged lymph nodes in groin, anemia, bilateral foot onychomycosis, lung disability, rhabdomyolysis of the kidney, residuals of a bacterial infection secondary to surgery, and bilateral foot ulcers, bilateral foot osteomyelitis, and right foot scar. The Board notes upon review of the medical evidence in the claims file that there is insufficient evidence to adjudicate whether the Veteran’s balance issues, excessive sweating, chronic fatigue syndrome, internal scarring, hyperkalemia, bronchitis, arteriovenous fistula, bilateral hand disability, enlarged lymph nodes in groin, anemia, bilateral foot onychomycosis, lung disability, rhabdomyolysis of the kidney, residuals of a bacterial infection secondary to surgery, bilateral foot ulcers, and bilateral foot osteomyelitis, and right foot scar are related to his now service connected diabetes, coronary artery disease, and/or hypothyroidism. Due to the complexity of the Veteran’s clinical picture before his death and the lack of any VA provided examination before his death, the Board finds that before adjudication can proceed a VA examiner should produce an opinion to address the appellant’s contention that these disabilities flowed from his now service-connected disabilities. The matters are REMANDED for the following action: 1. Contact the Appellant and request that she identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who had treated the Veteran for his disabilities. The Appellant should be requested to sign any necessary authorization for release of medical records to VA, and appropriate steps should be made to obtain any identified records. Notify the Appellant that the Board is interested in the medical evidence she said she provided to VA in her October 2020 VA correspondence. When she wrote that “Additional medical records were submitted at the South Carolina SC 29209 in hopes of a review. I also listed medical concerns on the MyHealthy Vet website in hopes that the doctors would read for the proper medication and requests for medical care.” If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. If the records are unavailable, notify the Appellant in accordance with 38 C.F.R. § 3.159. 2. After the above development is accomplished, obtain medical opinions from appropriate VA examiners per this directive. The claims folder (including a copy of this remand) must be provided to and reviewed by the examiners. A notation to the effect that this review has taken place should be made in the evaluation report. (A). BALANCE ISSUES: After reviewing the record, the VA examiner should identify any balance disabilities present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any balance issues identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (B) EXCESSIVE SWEATING: After reviewing the record, the VA examiner should identify any disability manifested by excessive sweating that was present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any excessive sweating disabilities identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (C) CHRONIC FATIGUE: After reviewing the record, the VA examiner should identify any chronic fatigue disabilities present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any chronic fatigue disabilities identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (D) HYPERKALEMIA: After reviewing the record, the VA examiner should identify any hyperkalemia present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any hyperkalemia identified was caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (E) BRONCHITIS: After reviewing the record, the VA examiner should identify any bronchitis present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any bronchitis identified was caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (F) ARTERIOVENOUS FISTULA: After reviewing the record, the VA examiner should identify any arteriovenous fistulas present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any arteriovenous fistulas identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (G) BILATERAL HAND DISABILITY: After reviewing the record, the VA examiner should identify any hand disabilities present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any hand disabilities identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (H) ENLARGED LYMPH NODES IN GROIN: After reviewing the record, the VA examiner should identify any lymph node disabilities present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any lymph node disabilities identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (I) ANEMIA: After reviewing the record, the VA examiner should identify whether anemia was present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any anemia identified was caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (J) BILATERAL FOOT ONYCHOMYCOSIS, ULCERS, OSTEOMYELITIS, SCARS: After reviewing the record, the VA examiner should identify any foot disabilities present, to include onychomycosis, ulcers, osteomyelitis or scars. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any foot disabilities identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (K) LUNG DISBAILITY: After reviewing the record, the VA examiner should identify any lung disabilities present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any lung disabilities identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (L) RHABDOMYOLYSIS OF THE KIDNEY: After reviewing the record, the VA examiner should identify any rhabdomyolysis of the kidney present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any rhabdomyolysis identified was caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (M) RESIDUALS OF A BACTERIAL INFECTION SECONDARY TO SURGERY: After reviewing the record, the VA examiner should identify any residuals of a bacterial infection present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any residuals identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. (N) INTERNAL SCARRING: After reviewing the record, the VA examiner should identify any internal scarring present. The examiner is then asked to opine as to whether it is at least as likely as not, i.e. 50 percent probability or greater, that any internal scarring identified were caused by or aggravated by any of the Veteran’s service connected disabilities, including diabetes mellitus type II, coronary artery disease, hypertension, or hypothyroidism. 3. Ensure that the any opinions provided comply with this remand and the questions presented in this request. If the report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 4. After completing the requested actions and any additional notification and/or development deemed warranted, readjudicate the issues on appeal, including TDIU. GAYLE E. STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Acosta, 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.