Citation Nr: 21063543 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 16-18 966A DATE: October 14, 2021 ORDER Entitlement to a disability rating in excess of 10 percent for rhinitis is denied. Entitlement to a compensable disability rating for chronic sinusitis prior to December 11, 2018 is denied. Entitlement to a disability rating in excess of 30 percent for chronic sinusitis from December 11, 2018 is denied. Entitlement to a compensable rating for gastroesophageal reflux disease (GERD) prior to July 7, 2016 is denied. Entitlement to a disability rating of 30 percent for GERD from July 7, 2016 is granted. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety, memory loss, bipolar disorder, depression, attention deficit disorder, and a sleep disorder other than sleep apnea, is granted. REMANDED Entitlement to service connection for a left wrist disability is remanded. Entitlement to service connection for hypertension is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran's rhinitis has not manifested as rhinitis with polyps. 2. Prior to December 11, 2018, the Veteran's service-connected sinusitis was not productive of three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. 3. From December 11, 2018, the Veteran's service-connected sinusitis is shown to have been symptomatic, but not requiring radical surgery with chronic osteomyelitis, or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 4. Prior to July 7, 2016, the Veteran's GERD resulted in reflux and no other significant symptoms and did not cause impairment in health. 5. From July 7, 2016, the Veteran's GERD presents with substernal pain, dysphagia, pyrosis, reflux, regurgitation, nausea, vomiting, and sleep disturbance but not material weight loss, melena with moderate anemia, or other symptom combinations productive of serious impairment of health. 6. After affording the Veteran the benefit of the doubt, the Veteran's acquired psychiatric disorder has been aggravated by his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for rhinitis have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.97, Diagnostic Code (DC) 6522. 2. The criteria for entitlement to a compensable disability rating for chronic sinusitis prior to December 11, 2018 have not been met. 38 U.S.C. § 1155, 5102, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.97 DC 6513. 3. The criteria for entitlement to a disability rating in excess of 30 percent for chronic sinusitis from December 11, 2018 have not been met. 38 U.S.C. § 1155, 5102, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.7, 4.97 DC 6513. 4. The criteria for entitlement to a compensable rating for GERD prior to July 7, 2016 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.31, 4.114, DC 7399-7346. 5. The criteria for entitlement to a disability rating of 30 percent for GERD from July 7, 2016 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.31, 4.114, DC 7399-7346. 6. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include anxiety, memory loss, bipolar disorder, depression, attention deficit disorder, and a sleep disorder other than sleep apnea, have been met. 38 U.S.C. §§ 1110, 1111, 1153, 5103(a), 5103A, 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 from January 2002 to January 2004, as well as subsequent Puerto Rico National Guard service. This matter was previously remanded by the Board of Veterans' Appeals (Board) in January 2019. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Court has held that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). Separate evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. Entitlement to a disability rating in excess of 10 percent for rhinitis The Veteran's service-connected rhinitis is currently rated 10 percent under DC 6522. Under DC 6522, a 10 percent disability rating is assigned for allergic rhinitis without polyps, but with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. A maximum 30 percent disability rating is assigned for allergic rhinitis with polyps. 38 C.F.R. § 4.97. After reviewing all the lay and medical evidence, the Board finds that at no time during the appeal period has the Veteran's rhinitis approximated rhinitis with polyps as required for a rating higher than 10 percent. The Veteran had an examination for his rhinitis in March 2015. Examination showed there was not a greater than 50 percent obstruction of the nasal passage on both sides, due to rhinitis. However, the examination also indicated that there was complete obstruction on both right and left sides. There was permanent hypertrophy of the nasal turbinates. Additionally, examination of the Veteran showed a lack of nasal polyps. The Veteran had another examination for his rhinitis in July 2016. Examination showed there was not a greater than 50 percent obstruction of the nasal passage on both sides, due to rhinitis. Furthermore, the examination also indicated that the Veteran did not have complete obstruction on either the right or left sides. There was permanent hypertrophy of the nasal turbinates. Additionally, examination of the Veteran showed a lack of nasal polyps. The Veteran had another examination for his rhinitis condition in March 2017. Examination showed there was a greater than 50 percent obstruction of the nasal passage on both sides, due to rhinitis. However, the obstruction was not complete. There was permanent hypertrophy of the nasal turbinates. Additionally, examination of the Veteran showed a lack of nasal polyps. The Veteran had another examination for his rhinitis condition in July 2017. Examination showed there was a greater than 50 percent obstruction of the nasal passage on both sides, due to rhinitis. There was evidence of complete obstruction on the left side due to rhinitis. However, there was no evidence of complete obstruction on the right side. There was permanent hypertrophy of the nasal turbinates. Additionally, examination of the Veteran showed a lack of nasal polyps. The Veteran had another examination for his rhinitis condition in April 2019. Examination showed there was a greater than 50 percent obstruction of the nasal passage on both sides, due to rhinitis. However, the obstruction was not complete. There was permanent hypertrophy of the nasal turbinates. Additionally, examination of the Veteran showed a lack of nasal polyps. Based on this evidence, the Board finds that the Veteran's rhinitis has not met or more nearly approximated allergic rhinitis with polyps for the entire period at issue as required for a maximum 30 percent rating. As the preponderance of the evidence is against the appeal for an initial disability rating in excess of 10 percent for allergic rhinitis, the appeal for a higher initial rating must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.97, DC 6522. In reaching its conclusion, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a compensable disability rating for chronic sinusitis prior to December 11, 2018 The Veteran is rated as 10 percent disabled under DC 6513 for his chronic sinusitis for the period on appeal prior to December 11, 2018. Under DC 6513, a 10 percent rating is warranted for one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is warranted for three or more incapacitating episodes per year requiring prolonged (lasting four to six weeks) antibiotic treatment, or more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent (maximum) rating is warranted following radical surgery with chronic osteomyelitis, or near constant sinusitis characterized by headaches, pain and tenderness of the affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97, DC 6513. An incapacitating episode of sinusitis means one that requires bed rest and treatment by a physician. Id., Note 1. The Veteran had an examination for his sinusitis in March 2015. The examiner reported that the Veteran had chronic sinusitis symptoms including pain of affected sinus. In the previous 12 months, the Veteran had no non-incapacitating episodes involving headaches, pain and purulent discharge or crusting and no incapacitating episodes or sinus surgeries. The Veteran had another examination for his sinusitis in July 2016. The examiner reported that the Veteran had chronic sinusitis symptoms including episodes of sinusitis and headaches. In the previous 12 months, the Veteran had no non-incapacitating episodes involving headaches, pain and purulent discharge or crusting and no incapacitating episodes or sinus surgeries. The Veteran had another examination for his sinusitis condition in March 2017. The examiner reported that the Veteran had chronic sinusitis symptoms including headaches and tenderness of affected sinus. In the previous 12 months, the Veteran had no non-incapacitating episodes involving headaches, pain and purulent discharge or crusting and no incapacitating episodes or sinus surgeries. The Veteran had another examination for his sinusitis condition in July 2017. The examiner reported that the Veteran had chronic sinusitis symptoms including headaches, pain of affected sinus, and tenderness of affected sinus. In the previous 12 months, the Veteran had no non-incapacitating episodes involving headaches, pain and purulent discharge or crusting and no incapacitating episodes or sinus surgeries. In order to warrant the next higher rating, the evidence must show three or more incapacitating episodes or more than six non-incapacitating episodes. The evidence of record for the period on appeal prior to December 11, 2018 indicates that the Veteran had no non-incapacitating or incapacitating episodes of sinusitis. As the evidence of record does not establish three or more incapacitating or at least six non-incapacitating episodes per year, entitlement to a rating in excess of 10 percent is not warranted for the period on appeal prior to December 11, 2018. 3. Entitlement to a disability rating in excess of 30 percent for chronic sinusitis from December 11, 2018 The Veteran is seeking a rating in excess of 30 percent for the period on appeal from December 11, 2018. The Veteran had an examination for his chronic sinusitis in April 2019. The examiner reported that the Veteran had chronic sinusitis symptoms including episodes of sinusitis, headaches, pain of affected sinus, and tenderness of affected sinus. The examiner also noted that the Veteran had 7 or more non-incapacitating episodes within the prior 12-month period, but none required prolonged antibiotics treatment during that time. The examiner also found that the Veteran had no incapacitating episodes. Additionally, the Veteran had no sinus surgeries. Based upon the evidence reported above entitlement to an evaluation in excess of 30 percent is not warranted for sinusitis for the period on appeal from December 11, 2018. As noted above, for a 50 percent rating under Diagnostic Code 6513, the evidence must show radical surgery with chronic osteomyelitis, or near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Such has not been shown in this case. The Veteran's April 2019 examination showed that the Veteran had 7 or more non-incapacitating episodes within the prior 12-month period, but none required prolonged antibiotics treatment during that time. Additionally, the examination showed that the Veteran did not have nasal surgery. Furthermore, there is no evidence that the Veteran suffered from near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. Therefore, the Board finds that the criteria for the next higher 50 percent rating have not been meet for the period on appeal from December 11, 2018. The Board finds that the preponderance of the evidence is against an increased rating and there is no doubt to be resolved. Accordingly, a disability rating in excess of 30 percent for chronic sinusitis for the period on appeal from December 11, 2018 is not warranted. 4. Entitlement to a compensable rating for GERD prior to July 7, 2016 The Veteran seeks a compensable disability rating for his service-connected GERD for the period on appeal prior to July 7, 2016 under 38 C.F.R. § 4.114, DC 7399-7346. The use of DC 7399 reflects that there is no diagnostic code specifically applicable to the Veteran's service-connected GERD, and that this disability has been rated by analogy to hiatal hernia in DC 7346. See 38 C.F.R. § 4.20 (allowing for rating of unlisted condition by analogy to closely related disease or injury). Under DC 7346, a 10 percent rating is warranted for hiatal hernia with two or more of the symptoms for the 30 percent rating of less severity; a 30 percent rating is warranted for hiatal hernia with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of a considerable impairment of health; and a 60 percent rating is warranted for hiatal hernia with symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health. 38 C.F.R. § 4.114, DC 7346. The Veteran had an examination for his GERD disability in March 2015. The Veteran was diagnosed with GERD. The Veteran reported symptoms including reflux. The examiner noted that the Veteran did not take continuous medication for his symptoms. The Veteran did not have an esophageal stricture, spasm of esophagus, or an acquired diverticulum of the esophagus. Additionally, the examiner reported that the Veteran's symptoms did not have an impact on his ability to work. The Board finds that the Veteran is not entitled to a compensable rating for service-connected GERD for the period on appeal prior to July 7, 2016. A compensable rating under Diagnostic Code 7346 requires two or more symptoms from the 30 percent evaluation of lesser severity, such as: dysphagia, pyrosis, regurgitation, or substernal arm or shoulder pain. The evidence of record indicates that the Veteran's GERD symptoms resulted in reflux, but no other symptoms. Additionally, the March 2015 examiner did not find any other pertinent physical findings, complications, conditions, or signs/symptoms attributed to the Veteran's GERD. Thus, a compensable rating is not warranted when considering Diagnostic Code 7346. The Board has considered whether the Veteran is entitled to a separate or higher evaluation based on any other applicable diagnostic code but has found no appropriate code that would allow for a higher or separate rating for the period on appeal prior to July 7, 2016. As a preponderance of the evidence is against the award of an increased rating, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). 5. Entitlement to a disability rating in excess of 10 percent for GERD from July 7, 2016 The Veteran contends that his service-connected GERD disability warrants a disability rating in excess of 10 percent for the period on appeal from July 7, 2016. The Veteran had an examination for his GERD in July 2016. The Veteran reported symptoms including pyrosis, reflux, regurgitation, and substernal pain. The Veteran reported taking continuous medication for his symptoms. Additionally, the examiner reported that the Veteran's symptoms did not have an impact on his ability to work. The Veteran had another examination for his GERD in March 2017. The Veteran reported symptoms including reflux and sleep disturbance caused by esophageal reflux four or more times per year. The Veteran had an examination for his stomach and duodenal conditions in July 2017. The examiner noted that the Veteran had a diagnosis of GERD and that the Veteran's treatment plan including taking continuous medication. Additionally, the examiner noted that the Veteran's symptoms included abdominal pain and mild nausea. The Veteran had another examination for his GERD in April 2019. The Veteran complained of symptoms including acid reflux, regurgitation, and heartburn, especially after meals. The Veteran further reported experiencing difficulty swallowing. The examiner noted that the Veteran exhibited symptoms including dysphagia, pyrosis, reflux, regurgitation, and sleep disturbance caused by esophageal reflux four or more times per year. The Veteran had another examination for his GERD in October 2020. The Veteran noted a burning sensation from epigastric to throat and on occasion with regurgitation into mouth with sour taste. The examiner noted that the Veteran experienced persistently recurrent epigastric distress, dysphagia, reflux, regurgitation, substernal pain, sleep disturbance caused by esophageal reflux four or more times per year, nausea, and vomiting. Resolving doubt in the Veteran's favor, the Board finds the Veteran's GERD presents with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation productive of considerable impairment of health during the period on appeal from July 7, 2016. The Veteran is competent to give evidence of symptoms observable by his senses, and the Board finds his report of symptoms credible. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, a 30 percent rating for GERD is warranted for the period on appeal from July 7, 2016. The evidence does not support assigment of a 60 percent rating for GERD. Specifically, during the period on appeal from July 7, 2016, the Veteran's GERD did not result in hematemesis, material weight loss, melena with anemia, or other symptoms productive of severe impairment of health. Although the Veteran reported symptoms including pain, nausea, and vomiting, the Veteran's GERD symptoms were not productive of severe impairment of health during the period on appeal from July 7, 2016. Accordingly, the Board finds a 30 percent rating is most appropriate based on the Veteran's disability picture during the period on appeal from July 7, 2016. See 38 C.F.R. § 4.114, DC 7346. 6. Entitlement to service connection for an acquired psychiatric disorder, to include anxiety, memory loss, bipolar disorder, depression, attention deficit disorder, and a sleep disorder other than sleep apnea The Veteran contends that entitlement to service connection is warranted for an acquired psychiatric disorder. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 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 between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be established on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. There is conflicting evidence of record as to whether the Veteran's current acquired psychiatric disorder was caused or aggravated by his service-connected disabilities. The Veteran had an examination for his acquired psychiatric disorder in March 2015. The examiner opined that the Veteran had no mental health diagnosis. The Veteran had another examination for his claimed acquired psychiatric disorder in July 2016. The examiner stated that the Veteran did not fulfill any of the DSM-5 symptoms criteria for a formal mental disorder diagnosis. The examiner stated that an opinion could not be rendered. The examiner noted that the Veteran was found with mild occasional feeling of anxiety, but these are not a full mental condition. The Veteran had another mental health examination in July 2017. The examiner opined that the Veteran's claimed condition was less likely than not proximately due to or the result of his service-connected condition. The examiner stated that the Veteran does not have symptoms that would meet the DSM-5 criteria for a diagnosis of a mental disorder. The Veteran had another mental health examination in December 2017. The examiner opined that the Veteran's claimed condition was less likely than not proximately due to or the result of his service-connected condition. The examiner stated that an opinion could not be furnished because there is no diagnosis on axis I. The examiner further noted that there is no medical evidence that fulfills any DSM-5 diagnostic criteria, and no neuropsychiatric condition was found at the time. The Veteran had another mental health examination in November 2018. The examiner noted that the Veteran had a diagnosis of bipolar disorder by history. The examiner opined that the Veteran's condition was less likely than not incurred in or caused by his active service. The examiner stated that the Veteran's bipolar disorder by history is not related to nor secondary to nor aggravated by military service nor any service-connected condition. The examiner stated that bipolar disorder is a neuropsychiatry condition related to affective disorder. The examiner noted that no relationship between bipolar disorder and military service was found in the medical literature. The Veteran had another examination for his claimed acquired psychiatric disorder, in the form of a private disability benefits questionnaire (DBQ) from Dr. E.C.R. in September 2019. Dr. E.C.R. opined that it is likely that his mental health condition of Bipolar disorder type II is being exacerbated by his condition of sleep apnea. Dr. E.C.R. stated that the Veteran's sleep apnea and bipolar disorder are related because the mood is affected for excessive tiredness. Dr. E.C.R. noted that the Veteran does not get good rest because of his problems with sleep apnea, which increases the bipolar symptoms like depression and/or irritability. Additionally, Dr. E.C.R. noted that the Veteran's symptoms of bipolar disorder continue to increment even after receiving psychiatric treatment. Dr. E.C.R. also noted that the Veteran's sleep apnea problems cause deterioration in work activity and general function in the Veteran including his mental health disorder. The Veteran had another mental health examination in October 2020. The examiner opined that the Veteran's currently diagnosed Bipolar II Disorder is less likely than not proximately due to or the result of his obstructive sleep apnea. The examiner stated that there are no medical rationales known to the evaluator that interconnect the development of symptoms associated with Type II Bipolar Disorder caused by obstructive sleep apnea. The examiner further stated that there is no clinical evidence that will support the affirmation of "the condition was made permanently worse beyond normal progression by the Veteran's sleep apnea". The examiner stated that reaching a conclusion that the Veteran's bipolar disorder has worsened was not sustainable at the time. The Veteran had another mental health examination in February 2021. The examiner opined that it was less likely than not that the Veteran's acquired psychiatric disorder was proximately due to or the result of his service-connected conditions. The examiner stated that the Veteran currently meets criteria for Unspecified Bipolar and Related Disorder, and unspecified alcohol-related disorder. The examiner noted that medical records do not support that the current diagnosis claimed as acquired psychiatric disorder to include anxiety, memory loss, bipolar disorder, depression, and attention deficit disorder, is at least as likely as not proximately due to or the result of the veteran's disabilities to include: Obstructive sleep apnea, Tinnitus and Rhinitis. The examiner stated that the etiology of the current diagnoses is unknown, due to multiple factors and for that reason the diagnoses are unspecified. The examiner further opined that it was less likely than not that the Veteran's acquired psychiatric disorder was aggravated beyond its natural progression by his service-connected disabilities. The examiner stated that the Veteran has reported improvement of symptoms over time and notes no aggravation. Additionally, the examiner stated that there is no medical evidence regarding mental health symptoms before the diagnosis of sleep apnea, therefore no baseline can be established for the Unspecified Bipolar and Related Disorder, and Unspecified alcohol-related disorder. The Board finds that the Veteran's current acquired psychiatric disorder, to include bipolar disorder, is at least as likely as not aggravated by his service-connected disabilities, specifically his service-connected sleep apnea. Pursuant to the "benefit-of-the-doubt" rule, where there is "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. 38 U.S.C. § 5107. Here, the Board finds that the aforementioned evidence is sufficient to place the relevant evidence, at a minimum, in a state of equipoise as to whether the Veteran's current acquired psychiatric disorder is caused or aggravated by his service-connected disabilities, principally his service-connected sleep apnea disability. Each of the opinions of record is supported by the underlying reasons for the conclusions reached. They are offered by competent medical professionals. While several are against the claim, one is decidedly for it. The Board finds that the approximate balance has been reached. Accordingly, the Board finds that service connection for an acquired psychiatric disorder is warranted. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a left wrist disability is remanded. The Veteran contends that he has a current left wrist disability that is related to his active service. The Veteran had an examination for his claimed left wrist disability in July 2016. The examiner noted that the Veteran had a diagnosis of a left wrist sprain. The examiner stated that a left wrist sprain is a condition with a clear and specific etiology and diagnosis not related to being exposed to environmental hazards during service in Southwest Asia. The examiner further stated that there is no evidence in the medical literature that supports any etiology that link actual left wrist condition to environmental hazards during service in Southwest Asia. The Board finds the July 2016 examination to be insufficient. It is not clear whether the examiner fully considered the Veteran's competent lay statements of record regarding the onset of his left wrist symptoms. Specifically, the Veteran has contended that his symptoms began during his active service and continued after service. Accordingly, remand is appropriate for an addendum medical opinion regarding the etiology of the Veteran's claimed left wrist disability. 2. Entitlement to service connection for hypertension is remanded. The Veteran contends that he has a current hypertension that is related to his active service. The Veteran had an examination for his claimed hypertension in July 2016. The examiner noted that the Veteran had a diagnosis of hypertension in 2014 but noted that the Veteran's high blood pressure is "suggestive of white coat syndrome". The examiner further stated that "[w]hite coat syndrome, is when the blood pressure is above the normal range, in a clinical setting, though they don't exhibit it in other settings... due to anxiety that those afflicted experience during a clinic visit". The Veteran had another examination for his claimed hypertension disability in October 2020. The examiner noted that the Veteran did not have a current diagnosis of hypertension. The examiner indicated that the Veteran was noted to have spikes of elevated blood pressure when anxious. The examiner stated that the Veteran has no current diagnosis of hypertension and had normal blood pressure readings on examination. The examiner further noted that the Veteran was not taking medications for elevated blood pressure. The Board finds the July 2016 and February 2020 examinations to be insufficient. It is not clear whether the Veteran had a diagnosed hypertension condition during the period on appeal. The Board notes that in McClain v. Nicholson, the Court held that the "current disability" requirement for service connection is satisfied if the Veteran had a disability at any point during the pendency of the claim-even if the disability completely resolved. 21 Vet. App. 319, 321 (2008). It is unclear whether the Veteran had a diagnosed hypertension condition, since the July 2016 examiner noted the Veteran had a diagnosis of hypertension in 2014. Accordingly, an opinion regarding the etiology of the Veteran's hypertension must still be obtained. Notably, a diagnosis of the disability in service is not required to establish service connection; rather, evidence after service may be sufficient to support a grant. As a result, a new VA medical opinion is required to clarify whether the Veteran has a current hypertension disability that is related to his active service. The matters are REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Obtain an opinion to address the etiology of the Veteran's claimed left wrist disability. The record must be made available to and reviewed by the VA examiner. Following a review of the entire record, the examiner is asked to address the following: Is it at least as likely as not (i.e., probability of 50 percent or greater) that a left wrist disability is related to the Veteran's active service, to include as a result of his in-service environmental exposures? In answering this question, review and consider the lay assertions of record. Also, note that the Veteran is competent to describe any symptoms he may have experienced since service discharge, particularly symptoms of a left wrist disability. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner should note that the lack of a diagnosed disability in service cannot serve as the sole basis for a negative finding. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 2. Schedule the Veteran for a VA examination to confirm whether he has a diagnosis of hypertension. The record must be made available to and reviewed by the VA examiner. All tests deemed necessary should be performed. Upon review of the file, the examiner should address each of the following: a) Confirm whether the Veteran has a current hypertension disability, or whether the Veteran has had a hypertension disability during the appeal that may have potentially resolved. If the Veteran has a current diagnosable hypertension disability at any point during the period on appeal, the examiner should address the following: b) Is it at least as likely as not (i.e., a 50 percent or greater probability) that a hypertension disability had its onset in, or is otherwise related to his period of active service to include as a result of the Veteran's in-service environmental exposures? c) Notwithstanding the above, is it at least as likely as not (i.e., a 50 percent or greater probability) that a hypertension disability was caused by the Veteran's service-connected disabilities, to include his service-connected sleep apnea, rhinitis, and chronic sinusitis disabilities? d) Notwithstanding the above, is it at least as likely as not (50 percent or greater probability) that a hypertension disability is aggravated by the Veteran's service-connected disabilities, to include his service-connected sleep apnea, rhinitis, and chronic sinusitis disabilities? Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner should note that the lack of a diagnosed disability in service cannot serve as the sole basis for a negative finding. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David M. Sebstead, 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.