Citation Nr: 21004523 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 15-29 269 DATE: January 27, 2021 ORDER Entitlement to service connection for a left hip disability, to include as secondary to service-connected bilateral knee disability is granted. Entitlement to service connection for a low back disability, to include as secondary to service-connected bilateral knee disability, is granted. REMANDED Entitlement to a disability rating greater than 10 percent for right knee instability is remanded. Entitlement to a disability rating greater than 10 percent for right knee limitation of flexion is remanded. Entitlement to a restoration of a 30 percent disability rating effective August 1, 2016 for right knee limitation of extension is remanded. Entitlement to a disability rating greater than 30 percent prior to August 1, 2016 and greater than 0 percent from August 1, 2016 for right knee limitation of extension is remanded. Entitlement to service connection for asthma is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for heart disability is remanded. FINDINGS OF FACT 1. Resolving all doubt in the Veteran's favor, his left hip disability is proximately due to, the result of, or aggravated by his service-connected bilateral knee disabilities. 2. Resolving all doubt in the Veteran's favor, his low back disability is proximately due to, the result of, or aggravated by his service-connected bilateral knee disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left hip disability to include, as secondary to service-connected bilateral knee disabilities are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to service connection for a low back disability to include, as secondary to service-connected bilateral knee disabilities are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served as a member of the United States Air Force, with active duty service from April 1984 through April 2004. This appeal comes to the Board of Veterans’ Appeals (Board) from a November 2013, July 2015 and May 2016 rating decisions, issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas (hereinafter Agency of Original Jurisdiction (AOJ)). In April 2018, the Veteran appeared and testified before the undersigned Veterans’ Law Judge at a Travel Board hearing, held at the RO. A transcript of this hearing has been reviewed and associated with the Veteran’s electronic claims file. The matter was previously before the Board in September 2018. As part of its remand directives, the AOJ was ordered to obtain VA examinations for the Veteran’s claims to service connection for sleep apnea, heart condition, asthma, left hip disability and low back disability. The Board also mandated that an updated examination that conforms with the ruling in Correia and Sharp, be obtained for the Veteran’s service-connected right knee disability. The matter has returned to the board for further appellate review. The procedural history of this appeal is complex, and a thoroughly detailed history may be seen in the September 2018 Board decision. However, with respect to the appeal involving the right knee limitation of extension, the Board has determined that the appeal includes a rating reduction claim and an increased rating claim. The Board will provide a summation of this history in the remand portion of the appeal. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the current disability and the disease or injury in service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). A disease first diagnosed after service may be service connected if all the evidence, including pertinent service records, establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may be considered on a secondary basis under 38 C.F.R. § 3.310. The three elements that must be met to grant secondary service connection are: (1) a current disability that is not already service-connected, (2) at least one service-connected disability, and (3) evidence that the non-service-connected disability is either: (a) proximately due to or the result of a service-connected disability, or (b) aggravated beyond its natural progress by a service-connected disability. 38 C.F.R. § 3.310. See Allen v. Brown, 7 Vet. App. 439 (1995). To meet the third element for service connection, the evidence must demonstrate an etiological relationship between a service-connected disability (knee disability) and the non-service-connected disability (back disability) as being proximately due to or the result of the service-connected disability. See Buckley v. West, 12 Vet. App. 76 (1998). In other words, there needs to be a nexus of the current disability and the service-connected disability for secondary service connection. Decisions of the Board shall be based on the entire record and consideration of all evidence, lay and medical, that is material. 38 U.S.C. § 7104(a); 38 U.S.C. § 5107(b); 38 C.F.R. § 3.303.(a). In evaluating the evidence in any given appeal, it is the responsibility of the Board to make appropriate determinations of (a) competence; (b) credibility; and (c) weight. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. When all the evidence is assembled, the VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 1. Entitlement to service connection for a left hip disability, to include as secondary to service-connected bilateral knee disabilities The Veteran contends that his left hip disability is related to service to include as due to service connected knee disabilities. Specifically, in several lay statements, the Veteran describes an onset of symptoms during service, including an altered gait, and how his service connected bilateral knee disabilities have contributed to his current left hip disability. See for e.g. November 2016 Correspondence. The Veteran has a hip disability which was diagnosed as osteoarthritis of the left hip in 1997. Thus, he meets the first criteria for service connection. Second, the Board notes that the Veteran is service connected for a bilateral knee disability. Thus, the second element for a secondary service connection is met. Id. The remaining question is whether there is a medical nexus between the Veteran's currently diagnosed left hip disability and his service-connected bilateral knee disabilities. The Veteran was afforded a VA Hip and Thigh examination in April 2015. The examiner opined that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner’s rationale was that the left hip condition which led to a total hip joint replacement in 2014 was osteoarthritis, not a traumatic injury. There was no serial, ongoing treatment for a hip condition after the resolution of an event in service in which the Veteran fell on his buttocks because of a rogue wave. The examiner noted that, the Veteran’s DJD of the hip is bilateral, which tends to support a DJD etiology as well. Regarding secondary service connection, the examiner rationalized that the etiology of the Veteran's knee condition is the same etiology as his left hip condition which required total hip arthroscopy in 2014. The examiner concluded that there is no evidence linking the Veteran’s hip condition with any traumatic injury or any in service event. The documented physical changes are entirely consistent with aging and normal wear in the joints. See April 2015 VA Examination. In a May 2015 addendum medical opinion, the examiner further concluded that the Veteran’s left hip disability was not caused or aggravated by the service connected left knee disability. In support of this rationale, the examiner explained that if the Veteran were to have altered his gait to accommodate for the service-connected left knee disability, this would have had a positive impact of the Veteran’s left hip, as there would be less weight-bearing motion. The Board accords the above opinions less probative weight because even though the Veteran is service-connected for bilateral knee disabilities, the examiner failed to discuss whether the left hip condition was related to the service-connected right knee disability. The Veteran was afforded a VA Hip and Thigh examination in January 2016. The Veteran reported that walking too much irritates the scar on his hip, and that his left hip will also become weak and tired with too much walking. The Veteran reported functional loss as an inability to ambulate for long periods of time. The examiner opined that the Veteran’s left hip disability is less likely than not due to the service-connected right knee disability. However, the examiner explained that the Veteran’s left hip replacement, and the service-connected left knee disability, likely contribute to symptoms of instability of the right knee. Continuing, the examiner then remarked that the shift in weight-bearing has “contributed to instability of the left hip.” See January 2016 C&P Examination. The Board finds this medical opinion to be internally inconsistent, as the examiner finds the left hip condition was not caused or aggravated by the service-connected right knee disability, but also finds that a shift in weight-bearing has contributed to the development of a left hip disability. Additionally, the Board notes that the examiner does not provide an opinion as to whether the service-connected left knee disability caused or aggravated the left hip disability. For the above reasons, the Board accords this opinion less probative weight. Following the Board’s remand of this issue in September 2018, the Veteran was afforded a VA Hip and Thigh examination in January 2020. The examiner opined that the claimed left hip joint replacement and left hip degenerative arthritis conditions are at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran’s service connected condition. The examiner provided the following rationale: that the objective examination done in January 2020 of left knee shows decrease in ROM, decrease in strength, crepitus, pain to palpation, and lateral instability; that service treatment records show the Veteran had left meniscal tear on August 2004, and fracture of left and right tibula and achilles tendon in 1993; that the Veteran also had right knee meniscal tear, and right rupture of Achilles tendon; that the Veteran worked as a medical provider responsible for transporting of injured soldiers to boats, airplanes, and trucks sometimes without help; and that all of the above factors contributed to the left hip disability along with lumbar derangement. See January 2020 C&P Examination. The Board assigns this opinion some probative weight. The January 2020 examiner conducted the examination in person and reviewed the entire claims folder. More importantly, the VA examiner's rationale is based on the evidence of record, sound medical reasoning, and is applied to the Veteran’s specific history. In August 2020, a VA examiner was asked to reconcile the conflicting medical opinions regarding the Veteran’s hip disability. The examiner opined that the condition claimed is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected condition. The examiner’s rationale was that no objective medical record or reputable medical literature evidence to indicate otherwise was found. The examiner noted that the Veteran's greatest risk factors for his hip disability are his obesity and the natural aging process. See August 2020 C&P Examination. The Board accords less probative weight to this examination and finds that the examiner's opinions ignored the pertinent medical and lay evidence of record and instead based his conclusion on an inaccurate/incomplete factual premise. After careful consideration, the Board finds that the evidence regarding nexus is at least in equipoise. When the evidence for and against a claim is in relative equipoise, the Board has an obligation to resolve all reasonable doubt in favor of the Veteran. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Resolving all reasonable doubt in the Veteran's favor, the Board finds that the third element of secondary service connection is established. See Wallin, 11 Vet. App. at 512. As all three elements of secondary service connection are met, service connection for left hip disability is warranted. 2. Entitlement to service connection for a low back disability to include, as secondary to service-connected bilateral knee disability The Veteran contends that his low back disability is related to his service to include as secondary to his service-connected bilateral knee disabilities. The first element to be met for secondary service connection is whether a current non-service-connected disability exists. In a September 2004 VA examination, examiner provided a diagnosis for arthritis of the lumbar spine, but this appear to be based off the Veteran's reported medical history, as examiner notes that x-rays are needed to confirm diagnosis. A September 2013 MRI of the lumbar spine however, noted mild degenerative changes to the lumbar spine. Therefore, the first element of a current non-service-connected back disability is met. The Veteran has service-connected knee disabilities. Thus, the Veteran has a service-connected condition, which would satisfy the second element for secondary service connection. The third element of whether a nexus exists between the back disability and the bilateral knee disabilities is less clear. The Veteran was afforded a VA examination in January 2005. The Veteran reported falling on his tailbone in service and stated that his physician did not follow him as closely as he would have liked; and that even though the injury healed, he questions whether it healed appropriately. He noted that his current symptoms include pain in the lower back and between his shoulder blades. The examiner noted an August 2003 diagnosis for osteoarthritis of the Veteran’s back but opined that it is less likely as not that 12 to 14 hours of military exercises caused the Veteran’s current back complaints. See January 2005 VA Examination. The Board accords this examination less probative value as the examiner did not explore other theories of service connection. Furthermore, the opinion did not proffer a detailed rationale for the negative nexus opinion. In January 2020, the Veteran underwent a VA Back Conditions examination. After reviewing the case file and an in-person examination of the Veteran, the examiner opined that the claimed lumbar strain condition is at least as likely as not ( 50 percent or greater probability) proximately due to or the result of the Veteran’s service connected knee disabilities, to include instability of the left knee and right knee. The examiner’s rationale was that objective examination of the back shows decrease in range of motion (ROM), decrease in strength, pain on ROM testing on extension, flexion, right and left lateral movement and use of assistive device when ambulating. The examiner continued that service treatment records and other medical records shows that the Veteran walks with an altered gait and has segmental dysfunction of the l/s area due to gait abnormality. The examiner also noted that service treatment record shows that Veteran suffered from left knee meniscus tear in August 2004, fibular fracture both legs in January 1993, right leg stress fracture in December 2004 and Achilles tendon rupture in January 1997. The examiner noted that in addition to the preceding injuries, the Veteran worked as a medical transporter moving injured soldiers into trucks, airplanes, boats, sometimes by himself and without a team member. The examiner concluded that taking into account all factors as mentioned above, it is more than probable that Veteran sustained injury to his back from above injuries and duties during military service. See January 2020 C&P examination. The Board finds that the January 2020 examiner’s opinion was based on the Veteran's accurate and complete medical history, included a rationale, and was based on sound reasoning. Thus, the probative value of this medical opinion is high. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In August 2020, a VA examiner was asked to reconcile conflicting medical evidence as it relates to the Veteran’s back disability. The examiner opined that the condition claimed is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service connected condition. The examiner’s rationale was that no objective medical record or reputable medical literature evidence to indicate otherwise was found. There is no mechanism of action for cause or permanent aggravation beyond natural progression of the Veteran's NTHCS lumbosacral spine and bilateral hip imaging diagnoses by arthritis, chondromalacia left knee/instability, left knee associated with arthritis, chondromalacia left knee/limitation of flexion, left knee associated with arthritis, chondromalacia left knee/scars, left knee, residual of surgical treatment associated with arthritis, chondromalacia left knee/right knee degenerative joint disease status post meniscal tear/instability right knee associated with right knee degenerative joint disease status post meniscal tear/limitation of extension, right knee, residual of meniscal tear associated with right knee degenerative joint disease status post meniscal tear. The examiner noted that the Veteran's greatest risk factors for his back disability are his obesity and the natural ageing process. See August 2020 C&P Examination. The Board accords less probative weight to this examination and finds that the examiner's opinions ignored the pertinent medical and lay evidence of record and instead based his conclusion on an inaccurate/incomplete factual premise. The examiner believes the Veteran's obesity and age caused wear and tear of the spine, but his rationale does not adequately elaborate on why this is so (since the Veteran has been pursuing the back claim more than 15 years ago). In addition, the examiner failed to consider private medical reports, evidencing the Veteran’s altered gait. Thus, the examiner's belief is unsupported, conclusory, and speculative at best. During his Board hearing, the Veteran specifically testified that his job in the Military included lifting up patients and loading them on a plane or truck, sometimes for 12 hours shifts. In addition to that, the Veteran stated that he had to sit hunched over people as a dental technician. The Veteran also testified that he believes his back disability may be related to the service connected bilateral knee disabilities. See April 2018 Hearing Transcript. While the Veteran cannot provide a medical diagnosis, he is competent to state if he experienced pain, and if he felt an altered alignment of his back. Further, the Board notes that this testimony corroborates medical evidence of record regarding the Veteran’s postural alterations. A review of the evidence suggests that there is probative medical evidence, in addition to the lay evidence, establishing that the Veteran's back disability is related to his service, or caused by or aggravated by his service-connected knee disability. Therefore, the third element for secondary service connection is met. In adjudicating this claim, the Board has considered the competent lay statements of record and accords more evidentiary weight to the January 2020 medical opinion, as well as the private and VA treatment records spanning the appellate period, which documents continued symptomatology of the Veteran's back pain. The Board finds that the Veteran has a current back disability during the appellate period that is related to Military service or secondary to his service-connected bilateral knee disabilities. Having satisfied the regulatory and statutory requirements of 38 C.F.R. § 3.310, 38 U.S.C. §§ 1110, 1131, entitlement to service connection for a low back disability, to include as secondary to a service-connected bilateral knee disability is granted. REASONS FOR REMAND 1. Entitlement to a disability rating greater than 10 percent for right knee instability is remanded. 2. Entitlement to a disability rating greater than 10 percent for right knee limitation of flexion is remanded. 3. Entitlement to a restoration of a 30 percent disability rating effective August 1, 2016 for right knee limitation of extension is remanded. 4. Entitlement to a disability rating greater than 30 percent prior to August 1, 2016 and greater than 0 percent from August 1, 2016 for right knee limitation of extension is remanded. As noted above, the Veteran’s right knee appeal has a complex procedural history. The Veteran is currently receiving three separate ratings for right knee disabilities. In a July 2015 rating decision, the Veteran’s right knee disabilities were rated under the following diagnostic codes (DC) as follows: (1) 30 percent for right knee limitation of extension under DC 5261; (2) 0 percent for right knee limitation of flexion under DC 5260 (3) 0 percent for right knee instability under DC 5257 In October 2015, the Veteran filed a Form 526EZ initiating a claim for an increased rating for his right knee meniscal tear. In March 2016 the AOJ issued a rating decision that: (1) Increased the Veteran’s right knee instability from 0 percent to 10 percent under DC 5257; (2) Increased the rating for the Veteran’s right knee limitation of flexion from 0 percent to 10 percent under DC 5260; (3) Proposed to reduce the 30 percent rating for limitation of extension under DC 5261. On March 13, 2016, the Veteran filed a timely notice of disagreement (NOD) to the right knee ratings for extension, flexion, and instability. In May 2016 the AOJ issued a rating decision that reduced the Veteran’s right knee limitation of extension from 30 percent to 0 percent effective from August 1, 2016. On May 16, 2016, the Veteran filed a timely NOD with respect to the reduction of his right knee limitation of extension. In May 2017, the AOJ issued a statement of the case (SOC) addressing the increased rating claim for the right knee limitation of extension but did not address the increased rating claims for right knee instability or right knee limitation of flexion. The AOJ has also not addressed in an SOC, the Veteran’s disagreement with the reduction of right knee limitation of extension effective August 1, 2016. The Board observes that to date, the AOJ has not promulgated SOC(s) addressing the Veteran’s increased rating claims for right knee instability, right knee limitation of flexion, and reduction of a 30 percent disability rating for right knee limitation of extension. Where a claimant files a notice of disagreement and the AOJ has not issued an SOC, the issue must be remanded to the AOJ for an SOC. See Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). Thus, the Board finds that, on remand, the AOJ must issue an SOC(s) addressing: (1) Whether a higher rating greater than 10 percent is warranted for the Veteran’s right knee instability under DC 5257. (2) Whether a higher rating greater than 10 percent is warranted for the veteran’s right knee limitation of flexion under DC 5260. (3) Whether the reduction of the right knee limitation of extension from 30 percent to 0 percent effective August 1, 2016 was proper. As the resolution of the increased rating claim for right knee limitation of extension is intertwined with the matter of determining whether the rating reduction was proper in the first place, adjudication of a disability rating greater than 30 percent prior to August 1, 2016 and greater than 0 percent from August 1, 2016 for right knee limitation of extension is deferred at this time and remanded as well. 5. Entitlement to service connection for asthma is remanded. 6. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. 7. Entitlement to service connection for heart disability is remanded. The Board finds that further development is necessary prior to analyzing the merits of the service connection claims for asthma, OSA and heart disabilities. Part of the Board’s remand directives included obtaining VA examinations and etiological opinions for the Veteran's service connection claims. Regarding the service connection claim for asthma, the Veteran was afforded a VA Respiratory Conditions examination in January 2020. The Veteran’s diagnoses included asthma and pulmonary embolus- bilateral lower lobe. The examiner opined that the claimed asthma and pulmonary embolus conditions were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner’s rationale was that although the Veteran does have some form of restrictive disease, chronic thrombo-pulmonary embolism, sleep apnea, and obesity, review of service treatment records during military service do not demonstrate asthma. The examiner also noted that on the Veteran’s separation examination, he marks “no” for asthma and is not on any medication; and that on the January 1984 medical examination the Veteran again marks “no” to asthma and taking no medication. Therefore, the Veteran’s existing restrictive disease is not related to military service. The Board finds this opinion inadequate. As noted earlier, the absence of in-service evidence of a disability during service is not always fatal to a service connection claim. Ledford v. Derwinski, 3 Vet. App. 87, 89. On remand a new examination that determines the etiology of the Veteran’s restrictive disabilities is warranted. Regarding the service connection claim for OSA, the Veteran was afforded a VA examination in January 2020. The examiner opined that the claimed OSA was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner’s rationale was that the Veteran’s service treatment records do not show that this condition occurred in or was caused by service. No complaints, diagnosis or treatment for this disorder is found in service treatment records reviewed during military service. Furthermore, service medical reports marks "no" to trouble sleeping. See January 2020 C&P Examination. The Board finds this examination inadequate. The examiner relied on a lack of in-service diagnosis or complaints of OSA in formulating his opinion. However, the absence of in-service evidence of a disability during service is not always fatal to a service connection claim. Ledford v. Derwinski, 3 Vet. App. 87, 89. On remand a new examination that determines the etiology of OSA is warranted. Regarding the Veteran’s claimed heart disability, he was afforded a VA examination in June 2020. The examiner noted that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness or caused by the claimed in-service injury, event, or illness to include elevated blood pressure readings noted at August 2000 dental exam. The examiner noted that he disagreed with the 2013 diagnoses of “Acute, subacute, or old myocardial infarction" (MI) as the diagnosis was based solely on the Veteran's history.” The examiner noted that VBA diagnostic criteria requires the diagnosis of MI to be confirmed by cardiac enzymes/isoenzymes and these were not found. The examiner further noted that the March 2012 NTHCS STRESS ECHO, the January 2016 Texas Health Hughley Transthoracic Echocardiogram, and the December 2015 Cardiac & Vascular Interventional Group Myocardial Perfusion Stress Test do not support or confirm the diagnosis of CAD, IHD, or MI. The examiner also stated that the Veteran was given a presumptive diagnosis of hypertension based on Dental Clinic blood pressures of 142/92 and 132/99 in August 2000 and that a diagnosis of hypertension was not confirmed by the 5 day follow-up blood pressure check. The examiner rationalized that no objective medical record or reputable medical literature evidence to indicate otherwise was found. The examiner stated that the Veteran was first started on antihypertensive therapy in May 2010 and that there is no immediate objective post service medical record evidence to indicate treatment for chronic/ongoing hypertension condition/pathology. The examiner concluded that the Veteran's CAD/IHD/MI if found is caused by the deposition of cholesterol plaque within the coronary arteries and not by the claimed in-service injury, event, or illness to include elevated blood pressure readings noted at August 2000 dental exam. The examiner further opined that the Veteran's CAD/IHD/MI if found is less likely than not (less than 50 percent probability) proximately due to or aggravated by the prostatic hypertrophy (BPH) or the medications used to treat such. The Board finds this examination inadequate. The examiner failed to discuss the Veteran’s complete history as evidenced in the treatment records. For example, less than a year after service, the Veteran was admitted for complaints of chest pain and shortness of breath which he asserts has continued to date. The Board also notes that diagnostic testing for MI as per VBA as proffered by the June 2020 examiner has not been done. Because the June 2020 opinion is based purely on review of available records (without in-person or video telehealth examination), a new VA examination is therefore warranted to capture the complete picture of the Veteran’s claimed heart disability if present. On remand, all required testing should be performed to ascertain a clear diagnosis. The matters are REMANDED for the following action: 1. Obtain any outstanding VA/private medical evidence pertinent to the issues on appeal. 2. Provide a Statement of the Case (SOC) to the Veteran and his attorney addressing the issues of: (1) a rating higher than 10 percent for right knee limitation of flexion; (2) a rating higher than 10 percent for right knee instability; (3) whether reduction of right knee limitation of extension from 30 percent to 0 percent effective August 1, 2016 was proper. A copy of any SOC issued should be included in the claims file. These claims should be returned to the Board only if the Veteran perfects a timely appeal. 3. Schedule Veteran for a VA examination to determine the etiology of his restrictive breathing disabilities. After completion of step 1above, the electronic claims file must be provided to and reviewed by the examiner in conjunction with the examination. All necessary diagnostic testing and evaluation should be performed, if necessary, and all findings set forth in detail. The examiner is requested to provide an opinion as to whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s asthma and pulmonary embolus-bilateral lower lobe disability is related to the Veteran’s service to include as secondary to any of his service connected disabilities. A complete rationale for the conclusions reached should be fully explained. 4. Obtain an opinion from a qualified clinician regarding the etiology of the Veteran’s OSA. After completion of step 1 above, the electronic claims file must be provided to and reviewed by the before providing an opinion. The examiner is requested to opine as to whether it is at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s OSA is related to the Veteran’s service to include as secondary to any of his service connected disabilities. A complete rationale for the conclusions reached should be fully explained. 5. Schedule the Veteran for an examination with a qualified clinician to determine the etiology of any heart disability. After completion of step 1 above, the electronic claims file must be provided to and reviewed by the examiner in conjunction with the examination. All necessary diagnostic testing (especially as mandated by the VBA diagnostic criteria) should be performed, and all findings set forth in detail. The examiner is requested to provide an opinion as to whether it is at least as likely as not (i.e. a 50 percent probability or greater) that any current heart disability is related to the Veteran’s service to include as secondary to his service connected disabilities. A complete rationale for the conclusions reached should be fully explained. 6. After accomplishing the development requested above, readjudicate the issues on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case (SSOC) and afforded the applicable time period to respond. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. M. Rogers, 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.