Citation Nr: 21062965 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 17-23 731 DATE: October 12, 2021 ORDER New and material evidence having been received, the application to reopen the previously denied claim of obstructive sleep apnea is granted. New and material evidence having been received, the application to reopen the previously denied claim of stomach pains as secondary to service-connected asthma is granted. New and material evidence having been received, the application to reopen the previously denied claim of acid reflux due to steroids prescribed for service-connected asthma is granted. New and material evidence having been received, the application to reopen the previously denied claim of esophagus damage (also claimed as difficulty swallowing and having to have your throat stretched) as secondary to acid reflux due to steroids prescribed for service-connected asthma is granted. New and material evidence having been received, the application to reopen the previously denied claim of hypertension (also claimed as vascular disease) as secondary to service-connected asthma is granted. The claim to reopen the previously denied claim of service heart condition (also claimed as sharp pains around heart) as secondary to service-connected asthma is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. REMANDED The issue of service connection for sleep apnea is remanded. The issue of service connection for stomach pains as secondary to service-connected asthma is remanded. The issue of service connection for acid reflux due to steroids prescribed for service-connected asthma is remanded. The issue of service connection for esophagus damage due to acid reflux secondary to service-connected asthma is remanded. The issue of service connection for hypertension (also claimed as vascular disease) as secondary to service-connected asthma is remanded. The issue of entitlement to an effective date earlier than June 26, 2015 and for a rating greater than 50 percent from June 26, 2015 for other unspecified trauma and stressor-related disorder and unspecified depressive disorder is remanded. FINDINGS OF FACT 1. The September 2010 rating decision denied, in pertinent part, the claims of service connection for sleep apnea, stomach pains as secondary to service-connected asthma, acid reflux due to steroids prescribed for service-connected asthma, acid reflux due to steroids prescribed for service-connected asthma, esophagus damage (also claimed as difficulty swallowing and having to have your throat stretched) as secondary to acid reflux due to steroids prescribed for service-connected asthma, hypertension (also claimed as vascular disease) as secondary to service-connected asthma, and heart condition (also claimed as sharp pains around heart) as secondary to service-connected asthma. Although the Veteran was notified of the RO's decision and his appellate rights, he did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of the issuance of that decision, and the decision is final. 2. The evidence received since the final September 2010 rating decision denying the claim of service connection for sleep apnea includes evidence which relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of service connection. 3. The evidence received since the final September 2010 rating decision denying the claim of stomach pains as secondary to service-connected asthma includes evidence which relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of service connection. 4. The evidence received since the final September 2010 rating decision denying the claim of includes evidence which relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of service connection. 5. The evidence received since the final September 2010 rating decision denying the claim of esophagus damage (also claimed as difficulty swallowing and having to have your throat stretched) as secondary to acid reflux due to steroids prescribed for service-connected asthma includes evidence which relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of service connection. 6. The evidence received since the final September 2010 rating decision denying the claim of hypertension (also claimed as vascular disease) as secondary to service-connected asthma includes evidence which relates to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claim of service connection. 7. Evidence received since the final September 2010 rating decision denying service connection for a heart condition (also claimed as sharp pains around heart) as secondary to service-connected asthma, does not include information that was not previously considered. 8. The weight of competent and credible evidence of record is against finding that the Veteran has had bilateral hearing loss at any time during or approximate to the pendency of the claim. 9. The weight of competent and credible evidence is against finding that tinnitus began during active service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The September 2010 rating decision denying the claims of service connection for sleep apnea, stomach pains as secondary to service-connected asthma, acid reflux due to steroids prescribed for service-connected asthma, acid reflux due to steroids prescribed for service-connected asthma, esophagus damage (also claimed as difficulty swallowing and having to have your throat stretched) as secondary to acid reflux due to steroids prescribed for service-connected asthma, hypertension (also claimed as vascular disease) as secondary to service-connected asthma, and heart condition (also claimed as sharp pains around heart) as secondary to service-connected asthma is final. 38 U.S.C. § 7105(c) (2002); 38 C.F.R. § 3.104, 20.302, 20.1103 (2009). 2. New and material evidence has been received to reopen the previously denied claim of service connection for sleep apnea. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.104, 3.156, 3.159, 20.302 (2020). 3. New and material evidence has been received to reopen the previously denied claim of service connection for stomach pains as secondary to service-connected asthma. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.104, 3.156, 3.159, 20.302 (2020). 4. New and material evidence has been received to reopen the previously denied claim of service connection for acid reflux due to steroids prescribed for service-connected asthma. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.104, 3.156, 3.159, 20.302 (2020). 5. New and material evidence has been received to reopen the previously denied claim of service connection for esophagus damage (also claimed as difficulty swallowing and having to have your throat stretched) as secondary to acid reflux due to steroids prescribed for service-connected asthma. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.104, 3.156, 3.159, 20.302 (2020). 6. New and material evidence has been received to reopen the previously denied claim of service hypertension (also claimed as vascular disease) as secondary to service-connected asthma. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.104, 3.156, 3.159, 20.302 (2020). 7. New and material evidence has not been received to reopen the previously denied claim of service connection for heart condition (also claimed as sharp pains around heart) as secondary to service-connected asthma. 38 U.S.C. § 5108 (2012); 38 C.F.R. §§ 3.104, 3.156, 3.159, 20.302 (2020). 8. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.385 (2020). 9. The criteria for service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the United States Navy from August 1987 to August 1997. This matter comes before the Board of Veterans' Appeals (Board) from a June 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted a Notice of Disagreement (NOD) in June 2015. In his initial claim filed in December 2014, the Veteran claimed service connection for PTSD and "anxiety/depression." In the April 2015 VA examination, however, the Veteran was diagnosed as having unspecified depressive disorder and other specified trauma and stressor-related disorder. In its June 2015 rating decision, however, the RO granted service connection for the disability claimed as PTSD and denied the claim of service connection for the disability claimed as anxiety and depression. In a November 2015 statement, the Veteran requested reconsideration of the rating assigned for PTSD. In a June 16, 2016 notice of disagreement, received by the RO on June 26, 2016, the Veteran expressed disagreement with the denial of service connection for "unspecified depressive disorder" possibly suggesting that it was different from "other specified trauma and stressor disorder" or that the rating and effective date did not consider the depressive disorder as warranting a higher or earlier rating. The RO granted an increase to 50 percent rating for service-connected "other unspecified trauma and stressor-related disorder and unspecified depressive disorder (posttraumatic stress disorder)" in a September 2016 rating decision. The RO acknowledged the additional diagnosis of depressive disorder, combined it with the PTSD as a single disorder but warranting a higher rating. This shows that the RO was considering the appeal as for an increased rating, In the rating decision, the RO lists "Notice of Disagreement received June 16, 2015" in its list of evidence, which is the date it was signed, but received on June 26, 2015. The RO then proceeded to state that the action "satisfies the issue on appeal (service connection for unspecified depressive disorder)." As the RO was considering the appeal to be that of a higher rating and effective date, it is a downstream issue, and the Veteran is presumed to be seeking the highest possible rating and earliest effective date for that rating. Considering the procedural history and to minimize prejudice to the Veteran, his initial claims of service connection for PTSD and "anxiety/depression" are read broadly and sympathetically to combine into a larger claim of service connection for "other unspecified trauma and stressor-related disorder and unspecified depressive disorder." The Board finds that the subsequent NOD must be interpreted as a disagreement with the initial rating and effective date assigned to the disability claimed as PTSD. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). In light of the remand below, the Veteran is not prejudiced by the Board's recharacterization of the issue on appeal. See Bernard v. Brown, 4 Vet. App. 384 (1993). A Statement of the Case (SOC) was issued in September 2016. However, in its September 2016 SOC, the RO did not address the claim of service connection for unspecified depressive disorder as it considered the claim satisfied, but it also did not address the remainder of the Veteran's claim. Specifically, the issue of an effective date earlier than June 26, 2015 and the issue of entitlement to a rating greater than 50 percent for service-connected "other unspecified trauma and stressor-related disorder and unspecified depressive disorder" from June 26, 2015 were not addressed. A remand is required for the RO to issue a statement of the case addressing the claim of entitlement to an effective date earlier than June 26, 2015 and for a rating greater than 50 percent from June 26, 2015 for other unspecified trauma and stressor-related disorder and unspecified depressive disorder. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The Veteran perfected an appeal by submitting a timely VA Form 9 in October 2016. The Veteran and his representative appeared in a May 2021 hearing. A transcript of that hearing has been associated with the record. At the hearing, the Veteran's representative requested that the record be kept open for 90 days to allow the appellant to submit additional medical evidence. That 90-day period has expired. 38 C.F.R. § 20.605. New and Material Evidence In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. See 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims such as this one, filed on or after August 29, 2001, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening the claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence related 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, to include by triggering the Secretary's duty to assist. Id. at 118. 1. Whether new and material evidence was received to reopen the previously denied claim of service connection for obstructive sleep apnea as secondary to service-connected asthma 2. Whether new and material evidence was received to reopen the previously denied claim of service connection stomach pains as secondary to service-connected asthma 3. Whether new and material evidence was received to reopen the previously denied claim of service connection for acid reflux due to steroids prescribed for service-connected asthma 4. Whether new and material evidence was received to reopen the previously denied claim of service connection for esophagus damage (also claimed as difficulty swallowing and having to have your throat stretched) as secondary to acid reflux due to steroids prescribed for service-connected asthma 5. Whether new and material evidence was received to reopen the previously denied claim of service connection for hypertension (also claimed as vascular disease) as secondary to service-connected asthma 6. Whether new and material evidence was received to reopen the previously denied claim of service connection for a heart condition (also claimed as sharp pains around heart) as secondary to service-connected asthma In September 2010, the RO denied the Veteran's claims of service connection for sleep apnea, acid reflux due to steroids prescribed for asthma, heart condition (also claimed as sharp pains around heart), stomach pains, esophagus damage (also claimed as difficulty swallowing and having to have your throat stretched) as secondary to acid reflux due to steroids prescribed for asthma, and hypertension. For the claim of service connection for sleep apnea as secondary to service-connected asthma, the RO found that there was no evidence of disability during military service, no objective medical evidence of a diagnosis or treatment for sleep apnea after discharge, and that the September 2010 VA examiner opined that the Veteran's sleep apnea was less likely than not related to the Veteran's service. The evidence reviewed by the RO included the Veteran's VA Medical Center treatment records from May 2000 to September 2010, a VA examination conducted in November 2009, addendum examination report from September 2010, and service treatment records from October 1986 to August 1997. In sum, the RO found that there was no medical evidence of the Veteran being diagnosed as having obstructive sleep apnea and that there was no medical opinion supporting the relationship of the contended sleep apnea to the medication prescribed for service-connected asthma. For the claim of service connection for stomach pains as secondary to service-connected asthma, the RO found no evidence of a disability during or after service and that pain alone, without a diagnosed or identifiable underlying malady or condition, did not constitute a disability. For the claim of service connection for acid reflux due to steroids prescribed for service-connected asthma, the RO found that there was no treatment for acid reflux during service and no evidence of linking the Veteran's acid reflux to the steroids prescribed for service-connected asthma. The RO noted that the September 2010 VA medical practitioner reviewed the Veteran's medical evidence of record and opined that it was less likely as not that the Veteran's acid reflux was caused by steroids prescribed for service-connected asthma. As rationale, the VA medical practitioner stated that the Veteran did not use routine systemic steroid therapy and that inhaled steroids were not medically known to cause gastrointestinal problems as they are not digested into the system by the gastrointestinal tract. The practitioner also opined that intermittent use of systemic steroids occurring once or twice a year for a short burst therapy of approximately 1 to 2 weeks was not medically known to cause problems. In summary, the RO found that the Veteran's acid reflux did not occur in service and that there was no medical opinion supporting a relationship between the Veteran's medication for service-connected asthma and his acid reflux. For the claim of service connection for esophagus damage as secondary to acid reflux due to steroids prescribed for asthma, the RO found that there was no medical evidence showing that it was directly connected to the Veteran's service. In addition, as discussed above, the RO found that the Veteran's acid reflux was not related to his service. In summary, the RO found that the Veteran's esophagus damage did not occur during service and that the contended cause of the esophagus damage, acid reflux, was not service-connected. For the claim of service connection for a heart condition as secondary to service-connected asthma, the RO found that there was no medical evidence of the Veteran being diagnosed as having a heart disability. For the claim of service connection for hypertension as secondary to service-connected asthma, the RO found that there was no medical evidence of hypertension during service and that contemporaneous blood pressure readings were asymptomatic. The Veteran also received treatment for elevated blood pressure after discharge without being diagnosed as having hypertension in May 2001, more than 3 years after discharge, and the first diagnosis for hypertension was in September 2003, or 6 years after discharge. The Veteran was notified of the denials in October 2010. The Veteran indicated that he wished to file an NOD in December 2010, and submitted a statement in November 2011 contesting, in pertinent part, the decisions denying service connection for sleep apnea, heart condition, hypertension, esophagus damage, stomach pains, and acid reflux. An SOC was issued in November 2012 continuing the denials and informing the Veteran that he must file his appeal within 60 days of receiving the SOC. The Veteran did not timely appeal his claims, and the Board finds that the September 2010 rating decision is final. In May 2014, VA Medical Center treatment records note that the Veteran "has sleep apnea and is getting reassessed." The medical practitioner did not list sleep apnea among the list of active problems or medical history, however, suggesting that the notation was a transcript of the Veteran's report rather than a diagnosis made following a sleep study. Records from December 2010 show that a consult for sleep apnea was placed, but there is no record of the Veteran receiving a sleep study. The list of active problems included gastroesophageal reflux disorder, essential hypertension, and "personal history of peptic ulcer disease" noted in between September and November 2009. In September 2014, the Veteran submitted a request to reopen to claims for sleep apnea, heart disease, vascular disease, esophagus, hernia, and stomach issues. The Veteran submitted a document detailing the events USS Wisconsin was involved in, and then stated that he had enclosed all the remaining information or evidence that will support his claim. In March 2015 and again in May 2015, VA Medical Center treatment records from July 2011 to May 2015 were added to the Veteran's file. The treatment records show the Veteran was diagnosed as having sleep apnea on February 26, 2015. The Veteran's active problem list in May 2015 did not include any new diagnoses relating to the Veteran's claims. In May 2015, the Veteran's heart had regular rate and rhythm, with no murmur, click, gallop, or rub. There were no medical evidence or medical opinions submitted or otherwise associated with the Veteran's file suggesting a causal relationship between the Veteran's claims and his service-connected asthma. In June 2015, the Veteran submitted a statement from a private medical practitioner who opined that posttraumatic stress disorder and sleep apnea was closely related as they affected similar parts of the brain. The medical practitioner then opined that "it is a possibility that injury in one area can modify function in another." In February 2016, VA Medical Center treatment records from May 2000 to May 2009 were added to the Veteran's file. The records show that the Veteran having an active problem of peptic ulcer in February 2009. There is no record of the Veteran being diagnosed with a heart disease despite regular examinations of his heart. VA Medical Center treatment records from February 2019 show that the Veteran's only cardiovascular disability or problem is hypertension, and that while the Veteran had a history of peptic ulcer disease, only gastroesophageal reflux disease (GERD) was active. In May 2021, the Veteran appeared at a hearing. In pertinent part, the Veteran did not specifically testify that he was diagnosed as having a heart condition or a heart disease. The Veteran testified that his doctor told him that "high blood pressure and all sorts of things" was due to his asthma or medication for his asthma, but also testified that he did not have the medical practitioner's statements in writing. In August 2021, the Veteran submitted a statement from a private practitioner who opined that the Veteran did not have a history of hypertension or asthma which "can heretofore be determined to be service-connected illnesses." Outside of stating that the Veteran did not have a history of hypertension, the practitioner did not support rationale for his opinion regarding the etiology of hypertension. Then, the private practitioner opined that the Veteran's reflux disease "exacerbate and extensively confound the comorbidities associated with his asthma" and that hypertension, asthma, reflux and esophagitis caused by reflux "not related to the [Veteran] until his inception into the United States military, are causative and contribute toward worsening morbidity." Again, outside of noting that the Veteran did not have hypertension, reflux, and esophagitis, the private practitioner did not offer any supporting rationale for his opinion. As an initial matter, the Board finds that there is no medical evidence, new or otherwise, that show the Veteran being diagnosed as having a heart disease or a heart condition. Thus, the application to reopen the previously denied claim of service connection for heart condition as secondary to service-connected asthma is denied. As for the remaining claims of service connection for obstructive sleep apnea, stomach pains, acid reflux, esophagus damage and hypertension, the Board finds that the evidence added to the Veteran's file are both new and material. The Veteran was diagnosed as having sleep apnea in February 2015, his past medical history included discussion of peptic ulcers, and the August 2021 private medical practitioner opined that the Veteran's acid reflux, esophagus damage, and hypertension were caused by the Veteran's service. As such, the claims are reopened and to this extent, the appeal to reopen the claims is granted. Service Connection Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for a disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability that is proximately due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Additional disability resulting from the aggravation of a nonservice-connected condition is also compensable under 38 C.F.R. § 3.310(a). Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for a disease diagnosed after discharge, when all 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, including an organic disease of the nervous system, like sensorineural hearing loss and tinnitus, 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 legally 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 for a chronic disease, 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). In addition to the criteria set forth above, service connection for impaired hearing is subject to the additional requirement of 38 C.F.R. § 3.385, which provides that impaired hearing will be considered to be a disability only if at least one of the thresholds for the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the thresholds for at least three of the frequencies are greater than 25 decibels; or speech recognition scores using the Maryland CNC Test are less than 94 percent. See also Hensley v. Brown, 5 Vet. App. 155 (1993). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. Id.; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." Gilbert, 1 Vet. App. at 54. 7. Service connection for bilateral hearing loss The Veteran contends that he has bilateral hearing loss that was caused by exposure to noise during military service. The Veteran underwent a VA examination in May 2015 for his bilateral hearing loss and tinnitus. The audiogram showed that the Veteran's pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 10 15 LEFT 10 10 10 10 10 The puretone threshold averages were 13 decibels for the right ear and 10 decibels for the left. His speech discrimination scores were 96 percent for the right ear and 96 percent for the left using the Maryland CNC wordlist. These results indicate that the Veteran has normal hearing bilaterally. The examiner opined that the Veteran had normal hearing sensitivity bilaterally. VA Medical Center treatment records from April 2018 show that the Veteran denied having hearing loss and tinnitus while complaining of suicidal intent and depression. The treatment records also show that the Veteran had "fair hearing" in December 2010, October 2011, July 2012, June 2013, and April 2014. The Veteran also did not report any ringing in his ears or tinnitus. Also, in January 2015, 4 months before the May 2015 VA examination, the Veteran did not report hearing loss or ringing in ears. In May 2021, the Veteran testified that he was a gunner's mate during service and fired weapons at least twice a week and that it contributed to his hearing loss. The Veteran also testified that he experienced "some ringing in the ears" then. During the hearing, the Veteran testified that he could get a hearing examination within 90 days as the most recent audiology examination was in 2015. Although the Board finds that service aboard an operating battleship while performing shore bombardment or gun exercises likely caused exposure to loud noise, the Veteran, however, did not submit any medical evidence supporting current bilateral hearing loss. Thus, after a review of the record, the Board finds that there is no medical evidence showing that the Veteran has bilateral hearing loss that meets VA criteria for a disability. The most recent audiology examination was the May 2015 VA examination where the results showed that the Veteran had normal hearing bilaterally. Moreover, the Board notes that the Veteran himself denied having any bilateral hearing loss in April 2018, which is the most recent medical evidence associated with the Veteran's file pertaining to his bilateral hearing. Therefore, the most probative evidence establishes that the Veteran does not have a current bilateral hearing loss and has not had one at any time during the pendency of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). In summary, there is no evidence of a current disability, in this case bilateral hearing loss, and the first of the three requirements for service connection is not met. See Shedden, 381 F.3d at 1167. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. 8. Service connection for tinnitus The Veteran contends that he has tinnitus caused by service. At the May 2015 VA examination, the Veteran reported intermittent bilateral tinnitus with onset "around 2000," or 3 years after discharge. The examiner found no record of contemporaneous complaints of tinnitus and opined that it was less likely than not related to the Veteran's military service as there was no hearing loss and its onset was after discharge. As discussed above, not only there is no medical opinion linking the Veteran's intermittent tinnitus to his active service, but the Veteran also did not report having continuous tinnitus since service. As discussed above, the Veteran testified that he had "some ringing" in service and had denied tinnitus until January 2015, four months before the May 2015 VA examination. The Veteran again denied having tinnitus in April 2018 before endorsing symptoms at the May 2021 hearing. It is well established that internal inconsistency, bias, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran may be considered. Caluza v. Brown, 7 Vet. App. 498, 511-12, aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curium) (table); Madden v. Gober, 125 Fed. Cir. 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). Given the inconsistencies and contradictions in the record, including the examples discussed above, the record does not establish onset of tinnitus during service nor continuous symptoms of tinnitus within a year of discharge. Therefore, the evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54. The preponderance of the evidence is against the Veteran's claim, and as such entitlement to service connection for tinnitus is denied. REASONS FOR REMAND 1. The issue of service connection for sleep apnea The Veteran contends that his sleep apnea is caused by his service-connected asthma. In the alternative, the Veteran contends that his sleep apnea is related to his service-connected other unspecified trauma and stressor-related disorder and unspecified depressive disorder. In June 2015, the Veteran submitted an email from a private university research professor of neurology who stated that posttraumatic stress disorder (PTSD), asthma, and sleep apnea were closely related because "many of the brain structure that are altered in such a way to cause the symptoms are the same structures, or at least, share functions." The private neurologist, however, did not review the Veteran's file nor opine on the Veteran's specific condition. He provided a physiological explanation that asthma constricts the bronchi of the lungs and that this is mediated by higher brain areas that are also involved in PTSD and sleep apnea. He further explained that brain areas injured by stress can modify function in other areas. This general theory lacks specificity for the lay adjudicator to apply to the Veteran's case as well as specificity on how stress damages the same neurological features that control breathing. Therefore, it does not have any probative weight outside of suggesting that here is a possibility of a nexus between the Veteran's service-connected asthma, other unspecified trauma and stressor-related disorder and unspecified depressive disorder, and sleep apnea may exist in the Veteran's case. See, e.g., Mattern v. West, 12 Vet. App. 222, 228 (1999) (generic texts, which do not address the facts in this particular case with any degree of medical certainty, do not amount to competent medical evidence). This theory requires further explanation for the lay reader. The Board also observes that the Veteran is currently not diagnosed as having PTSD, as discussed in the June 2019 VA examination, likely rendering the June 2015 statement by the private neurologist even less pertinent to the Veteran's case. Moreover, it is not clear whether the Veteran has been diagnosed with obstructive or central sleep apnea, the latter more closely related with neurological rather than physical structures. Thus, there is no adequate medical opinion that is necessary to decide on the claim. VA's duty to assist also includes obtaining a medical examination or opinion when such is necessary to decide on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). An examination or medical opinion is necessary if the evidence of record (1) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and (2) establishes that the claimant suffered an event, injury, or disease in service; or has a presumptive disease or symptoms of such a disease manifesting during an applicable presumptive period; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service; but (4) does not contain sufficient medical evidence for the Secretary to make a decision on the claim. Id.; see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). With respect to the claim of service connection for sleep apnea, the statutory duty to assist has been triggered, as the Veteran contended that his current sleep apnea, diagnosed in February 2015 is causally related to his other unspecified trauma and stressor-related disorder and unspecified depressive disorder. He has not yet been afforded an examination for this claim. The Board thus finds that the Veteran should be afforded an appropriate examination. 2. The issue of service connection for stomach pains as secondary to service-connected asthma The Veteran contends that he has stomach pains that was caused by his service-connected asthma. In December 2010, the Veteran submitted medical literature stating that Albuterol, medication prescribed for his asthma, could cause vomiting and sore throat. The Veteran was diagnosed as having peptic ulcer in February 2009. The September 2010 VA examiner opined that the Veteran's asthma therapy consisted of inhaled steroid therapy that is not medically known to cause gastritis and that intermittent use of steroids as reported by the Veteran is also not known to cause gastrointestinal problems. The examiner, however, did not specifically opine on the Veteran's claim of stomach pains or peptic ulcer, disabilities that are not necessarily synonymous with gastritis. Nor did the examiner specifically discuss whether the Veteran's peptic ulcer was aggravated by medication used by the Veteran. Secondary service connection is a two-part issue that involves causation and/or aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (holding that secondary service connection is a two-part issue that involves causation and/or aggravation); 38 C.F.R. § 3.310 (providing that "[a]ny increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected"). The Court had held that a medical opinion that focuses solely on causation is inadequate to address whether a service-connected disability aggravated another condition. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Thus, because the VA examiner did not address the second element of secondary service connection, the September 2010 VA opinion is inadequate for rating purposes. Accordingly, it necessary to remand the Veteran's claim of service connection for stomach pains for additional development. This is so because once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr, 21 Vet. App. at 331. 3. The issue of service connection for acid reflux due to steroids prescribed for service-connected asthma The Veteran also contends that his acid reflux was caused by steroids prescribed for service-connected asthma. The Veteran's claim was denied in September 2010 based on a VA medical opinion made in the same month. The examiner opined that the Veteran's acid reflux was less likely than not related to his steroids prescribed for asthma. As rationale, the examiner stated that the Veteran does not use routine systemic steroid therapy, that inhaled steroids are not medically known to cause gastrointestinal problems, and that the Veteran's reported use of systemic steroids 1-2 times a year for short burst therapy of approximately 1-2 weeks during acute exacerbation was also not medically known to cause problems. The examiner, however, did not address whether the Veteran's acid reflux was aggravated by asthma medication. See Allen, 7 Vet. App. at 448; 38 C.F.R. § 3.310; see also El-Amin, 26 Vet. App. at 140. In December 2018, the Veteran underwent a VA examination for his service-connected asthma. The examiner noted that the Veteran "recently started Montelukast" and that the Veteran did not use any oral steroids or medication other than inhaled medications. The examiner also noted that the Veteran did not have any other pertinent physical findings, complications, signs or symptoms related to his service-connected asthma. As the examination was for the Veteran's service-connected asthma, there was no discussion of the Veteran's medication and whether it may be related to the Veteran's acid reflux. In August 2021, the Veteran submitted a private medical opinion that the Veteran's asthma, reflux disease manifesting as erosive esophagitis, and hypertension were "not related to the [Veteran] until his inception into the United States military, are causative, and contribute toward worsening morbidity." The private practitioner did not offer any other rationale for his implicit opinion linking the Veteran's acid reflux to his military service and did not opine whether the Veteran's medication for asthma caused the Veteran's acid reflux. Thus, the Board finds the private medical opinion to be inadequate for rating purposes. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Again, secondary service connection is a two-part issue that involves causation and/or aggravation. Thus, because neither examiner addressed the second element of secondary service connection, specifically aggravation, the opinions are inadequate for rating purposes. Accordingly, it necessary to remand the Veteran's claim of service connection for acid reflux for additional development. This is so because once VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr, 21 Vet. App. at 331. 4. The issue of service connection for esophagus damage (also claimed as difficulty swallowing and having to have your throat stretched) as secondary to acid reflux due to steroids prescribed for service-connected asthma The Veteran contends that his esophagus damage was caused by acid reflux. The claim of esophagus damage, however, is inextricably intertwined with the remanded claim of service connection for acid reflux as the decision will affect the esophagus damage claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (noting that two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Thus, consideration of the appeal regarding service connection for esophagus damage will be deferred. 5. The issue of service connection for hypertension (also claimed as vascular disease) as secondary to service-connected asthma The Veteran contends that his hypertension is caused by his service-connected asthma. As discussed above, in August 2021, the Veteran submitted a private medical opinion that the Veteran's asthma, reflux disease manifesting as erosive esophagitis, and hypertension were "not related to the [Veteran] until his inception into the United States military, are causative, and contribute toward worsening morbidity." The private practitioner did not offer any other rationale for his implicit opinion linking the Veteran's hypertension to his military service and did not opine whether the asthma caused, or aggravated, the Veteran's hypertension. Thus, the Board finds the private medical opinion to be inadequate for rating purposes. See Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124. VA's duty to assist also includes obtaining a medical examination or opinion when such is necessary to decide on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). An examination or medical opinion is necessary if the evidence of record (1) contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; and (2) establishes that the claimant suffered an event, injury, or disease in service; or has a presumptive disease or symptoms of such a disease manifesting during an applicable presumptive period; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service; but (4) does not contain sufficient medical evidence for the Secretary to make a decision on the claim. Id.; see also McLendon, 20 Vet. App. at 79. With respect to the claim of service connection for hypertension, the statutory duty to assist has been triggered, as the Veteran contended, with supporting medical opinion, that his current hypertension is causally related to, or aggravated by, his other unspecified trauma and stressor-related disorder and unspecified depressive disorder. He has not yet been afforded an examination for this claim. The Board thus finds that the Veteran should be afforded an appropriate examination. 6. The issue of entitlement to an effective date earlier than June 26, 2015 and for a rating greater than 50 percent from June 26, 2015 for other unspecified trauma and stressor-related disorder and unspecified depressive disorder As discussed above, a September 2016 rating decision granted a rating of 50 percent disabling for other specified trauma and stressor-related disorder and unspecified depressive disorder effective June 26, 2015 and found that it satisfied the claim of service connection for unspecified depressive disorder. Again, as discussed at length above, construing the Veteran's claims for PTSD and "anxiety/depression" broadly and sympathetically, the RO did not address the remainder of the Veteran's claim in an SOC. Specifically, the issue of an effective date earlier than June 26, 2015 and the issue of entitlement to a rating greater than 50 percent for service-connected "other unspecified trauma and stressor-related disorder and unspecified depressive disorder" from June 26, 2015 were not addressed. A remand is required for the RO to issue a statement of the case addressing the claim of entitlement to an effective date earlier than June 26, 2015 and for a rating greater than 50 percent from June 26, 2015 for other unspecified trauma and stressor-related disorder and unspecified depressive disorder. 38 C.F.R. § 20.200; Manlincon, 12 Vet. App. at 240-41. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by a VA clinician to determine the nature and etiology of the Veteran's sleep apnea. The examiner should review the virtual file. The examiner is to address the following: (a). Does the Veteran have obstructive sleep apnea or central sleep apnea and is the Veteran's interrupted sleep caused by physical, neurological, or psychiatric causes? (b) Whether it is at least as likely as not (50 percent or greater probability) that sleep apnea manifested during or is otherwise caused by the Veteran's period of active service. (c). Whether it is at least as likely as not (50 percent or greater probability) that sleep apnea was caused or aggravated by service or a service-connected disability. The examiner is advised that aggravation means any increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered, to include the June 2015 private medical opinion. If an opinion cannot be given without resorting to speculation, the clinician should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the clinician (does not have the knowledge or training). 2. Schedule the Veteran for an examination by a VA clinician to determine the nature and etiology of the Veteran's stomach pains (peptic ulcer) as secondary to service-connected asthma. The examiner should review the virtual file. The examiner is to address the following: (a.) Whether it is at least as likely as not that peptic ulcer manifested during or is otherwise caused by the Veteran's period of active service. (b.) Whether it is at least as likely as not that peptic ulcer was caused or aggravated by service or a service-connected disability. The examiner is advised that aggravation means any increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the clinician should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge, the record, or the clinician. 3. Schedule the Veteran for an examination by a VA clinician to determine the nature and etiology of the Veteran's acid reflux as secondary to service-connected asthma and esophagus damage as secondary to acid reflux. The examiner should review the virtual file. The examiner is to address the following: (a.) Whether it is at least as likely as not that acid reflux ulcer manifested during or is otherwise caused by the Veteran's period of active service. (b.) Whether it is at least as likely as not that acid reflux was caused or aggravated by service or a service-connected disability. The examiner is advised that aggravation means any increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. (c.) Whether it is at least as likely as that esophagus damage was caused or aggravated by acid reflux. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered, to include the August 2021 private medical opinion. If an opinion cannot be given without resorting to speculation, the clinician should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge, the record, or the clinician. 4. Schedule the Veteran for an examination by a VA clinician to determine the nature and etiology of the Veteran's hypertension as secondary to service-connected asthma. The examiner should review the virtual file. The examiner is to address the following: (a.) Whether it is at least as likely as not that hypertension manifested during or is otherwise caused by the Veteran's period of active service. (b.) Whether it is at least as likely as not that hypertension was caused or aggravated by service or a service-connected disability. The examiner is advised that aggravation means any increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. A rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered, to include the August 2021 private medical opinion. If an opinion cannot be given without resorting to speculation, the clinician should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge, the record, or the clinician. 5. Send the Veteran an SOC that addresses the issue of entitlement to an effective date earlier than June 26, 2015 and for a rating greater than 50 percent from June 26, 2015 for other unspecified trauma and stressor-related disorder and unspecified depressive disorder. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H.S. Yun, 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.