Citation Nr: 21063762 Decision Date: 10/15/21 Archive Date: 10/15/21 DOCKET NO. 14-37 005 DATE: October 15, 2021 ORDER Entitlement to an initial disability rating greater than 30 percent for migraine headaches is denied. Entitlement to a rating greater than 10 percent prior to June 3, 2015 for dyspepsia (claimed as gastroesophageal reflux disease (GERD)/irritable bowel syndrome (IBS)) is denied. Entitlement to a 30 percent rating, but no higher, is granted for dyspepsia beginning June 3, 2015. REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a lumbosacral spine disability, to include as due to service-connected obstructive sleep apnea, is remanded. Entitlement to service connection for a cervical spine disability, to include as due to service-connected obstructive sleep apnea (OSA), is remanded. Entitlement to a TDIU, due to service-connected disabilities, before September 30, 2013, is remanded. FINDINGS OF FACT 1. The probative evidence of record shows that the Veteran's migraine headache does not cause very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 2. Before June 3, 2015, the Veteran's dyspepsia was not manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 3. At his June 3, 2015 hearing, the Veteran provided examples of how his dyspepsia had increased in severity. A May 2018 VA examination showed that the Veteran had persistently recurrent epigastric distress with pyrosis, regurgitation, substernal arm pain, vomiting, productive of considerable impairment of health. 4. The Veteran's dyspepsia is not accompanied by material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 30 percent for migraine headaches are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8100. 2. Before June 3, 2015, the criteria for a 30 percent disability rating for dyspepsia were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.114, Diagnostic Code 7399-7346. 3. Beginning June 3, 2015, a 30 percent disability rating for dyspepsia is warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.114, Diagnostic Code 7399-7346. 4. The criteria for a 60 percent disability rating for dyspepsia have not been met during the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.114, Diagnostic Code 7399-7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1991 to August 1993. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2012 and March 2014 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The rating decision of January 2012 granted service connection for migraine headaches, at 30 percent disabling, effective April 22, 2011, and denied service connection for a lumbosacral spine disability (characterized as subligamentous disc protrusion L5-S1 claimed as lumbar degenerative disc disease). The March 2014 rating decision granted service connection for a GERD (characterized as dyspepsia), at 10 percent disabling, effective September 30, 2013, and denied service connection for a cervical spine disability. A rating decision of March 2021 granted a 30 percent for dyspepsia, effective May 07, 2018. As the Veteran seeks a higher rating, it will generally be presumed that the maximum benefit allowed by law and regulation is sought. The claim remains in controversy where less than the maximum benefit available is awarded. AB v. Brown, 6 Vet. App. 35 (1993). In June 2015, the Veteran testified at a Board hearing before a Veterans Law Judge (VLJ). A copy of the transcript is of record. As the VLJ who presided over the hearing is no longer at the Board, the Veteran was afforded an opportunity for another hearing before a different VLJ. In April 2020, the Board received notice that he did not want an additional hearing. The issues were twice before the Board in December 2017 and November 2020. In December 2017, the Board directed the AOJ to provide the Veteran with examinations to determine the current severity of his migraines and gastrointestinal condition. He underwent VA examinations for these conditions in August 2018. The VA examinations are adequate because they were based upon consideration of the Veteran's pertinent medical history, his lay assertions and current complaints, and because they describe his migraines and gastrointestinal condition in detail sufficient to allow the Board to make a fully informed determination. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). There was substantial compliance with the remand directives with respect to the issues decided below. Stegall v. West, 11 Vet. App. 268 (1998). The most recent remand of November 2020 mandated that the RO issue a Supplemental Statement of the Case (SSOC) for the above-said issues. 38 C.F.R. § 19.31. As the SSOC was issued in March 2021, the Board finds there has been substantial compliance with the remand directives with respect to the issues decided below. Id. The Board has jurisdiction to consider entitlement to a TDIU as part of the underlying increased rating claims. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009); Payne v. Wilkie, 31 Vet. App. 373 (2019); Harper v. Wilkie, 30 Vet. App. 356 (2018). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). Here, although a TDIU was granted, effective September 30, 2013, the RO on January 28, 2013, received the Veteran's notice of disagreement (NOD) challenging the 10 percent disability rating assigned for migraine headache, and a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) in May 2013 wherein the Veteran attributed his inability to work due to his service-connected acquired psychiatric disorder and migraine headache disability, and non-service-connected back disability. Thus, a TDIU before September 30, 2013, is on appeal. Increased Rating Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.20. Where there is a question as to which of two evaluations shall be applied under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the claimant. 38 C.F.R. § 4.3. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007) (citing Fenderson v. West, 12 Vet. App. 119, 126 (1999)). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a competent source. Second, the Board must determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303 (2007). Third, the Board must weigh the probative value of the evidence considering the entirety of the record. Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 1. Entitlement to an initial disability rating greater than 30 percent for migraine headaches is denied. The Veteran's migraine headache disability is assigned a 30 percent disability rating under Diagnostic Code 8100. Under Diagnostic Code 8100, a 30 percent rating is warranted for characteristic prostrating attacks occurring on an average once a month over the last several months. A maximum 50 percent rating is warranted for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, Diagnostic Code 8100. The criteria for rating migraines are successive. Johnson v. Wilkie, 30 Vet. App. 245, 247 (2018). Successive criteria exist where the evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the Veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2008). Although 38 C.F.R. §§ 4.7 and 4.21 generally provide that symptoms need only more nearly approximate the criteria for a higher rating to warrant such a rating, those regulations do not apply where the rating schedule establishes successive criteria. The phrase "completely prostrating" (which is required for a 50 percent rating) is defined as "completely lacking in vitality or will" and "powerless to rise." Johnson v. Wilkie, 30 Vet. App. 245 (2018). This phrase means the headaches "must render the veteran entirely powerless." Id. at 253. This differs from "characteristic prostrating" (which is required for a 30 percent rating), which means that the migraine attacks "typically produce powerlessness or a lack of vitality." Further, "prolonged" has been defined as "to lengthen in time: extend duration: draw out: continue, protract." Id. "[P]roductive of severe economic inadaptability" has been defined as either 'producing' or 'capable of producing' severe economic inadaptability." Pierce v. Principi, 18 Vet. App. 440 (2004). The Veteran's private and VA treatment records show complaints and treatment for migraine headaches. The record also shows numerous VA examinations addressing the severity of the said headaches. For example, during a Neurological Disorders, Miscellaneous examination of September 2011, the Veteran reported intermittent hemicrania more on the left, over the eye that spread backwards to the nape of the neck. The attacks occurred weekly, and most of the attacks were identified as prostrating. When the attacks occurred, he needed to be secluded for most of the episodes. The headaches interfered with his usual occupation by causing increased tardiness, absenteeism, and pain. His headaches affected his daily activities by inhibiting the ability to perform usual household chores when prostrating attacks occurred. The examiner diagnosed migraine headaches. In an October 2014 VA headache examination, the Veteran reported constant throbbing headaches (6/10, pain scale: both sides) with sensitivity to light, sound, and monthly exacerbations associated with nausea that forced him to stay in bed (i.e., prostrating) for two days. The Veteran also reported experiencing constant head pain, pulsating or throbbing head pain, and pain on both sides of the head. He also reported non headache pain, nausea, sensitivity to light, and sensitivity to sound. The typical head pain lasted one to two days and was located on both sides of the head. He reported characteristic prostrating attacks of migraine/non-migraine headache pain, on average, once every month. The examiner noted that he did not have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability. The Veteran's headache condition did not impact his ability to work. During a May 2018 Headache examination, the Veteran reported constant daily throbbing headaches (6/10, pain scale: both sides) with sensitivity to light and sound, worst with prolonged exercise. The weekly exacerbations were associated with nausea and vomiting. He was also forced to stay in bed (i.e., prostrating) when for the lasting two days. During both the May 2018 and August 2018 Headache examinations, the Veteran reported that he experienced constant headache pain, pulsating or throbbing head pain, pain on both sides of the head, and pain that worsened with physical activity. The Veteran also experienced non-headache symptoms associated with headaches, including nausea, vomiting, sensitivity to light, and sensitivity to sound. The examiner indicated that the Veteran had constant throbbing headaches (6/10, pain scale: both sides) with sensitivity to light, sound, and weekly exacerbations associated with nausea which forced him to stay in bed (i.e., prostrating) and lasting two days. The location was noted as both sides of the head. The Veteran had characteristic prostrating attacks of migraine/non-migraine headache pain once every month. The Veteran did not have very prostrating and prolonged attacks of migraines/non-migraine pain productive of severe economic inadaptability nor any other pertinent physical findings, complications, conditions, signs, or symptoms related to a migraine headache disorder. The examiners determined that the Veteran's headache condition did not impact his ability to work. The August 2018 examiner additionally noted that "with this condition alone, the [Veteran] can still seek a job, at least on a part-time sedentary basis." In addition to the above VA examinations, the record contains June 2014 private Headache Disability Benefits Questionnaire (DBQ), wherein the clinician diagnosed migraine and tension headaches. He noted that the Veteran reported two to four migraine headaches per week but also complained of tension headaches. He experienced constant headache pain, pulsating or throbbing head pain; the pain worsened with physical activity and diffused head pain. The Veteran also experienced non-headache pain, including nausea, vomiting, sensitivity to light, sensitivity to sound, changes in vision, and sensory changes (such as the feeling of pins and needles in extremities). The duration of the typical head pain lasted two to four days in duration. The migraine headaches lasted eight to twelve hours, while the tension headaches were noted as constant. The clinician noted that the Veteran had characteristic attacks of migraine headache pain, more frequently than once per month, and very frequent prostrating and prolonged attacks of migraine headache pain. The Veteran also had prostrating attacks of non-migraine headache pain more frequently than once per month. The Veteran, however, did not have very frequent prostrating and prolonged attacks of non-migraines headache pain. Regarding whether the Veteran had any other pertinent physical findings, complications, conditions, signs, or symptoms related to his migraine diagnosis, the clinician noted that he had cervical spasms and TMJ pain. The examiner also noted that the Veteran's migraine disability impacted his ability to work because he is always in pain. A duplicate private headache BDQ dated in May 2015 additionally noted that the Veteran had been unable to work because of his service-connected disabilities. Furthermore, of record is the June 2015 argument by the Veteran's representative that his migraine headaches kept him in bed with secondary manifestations of dizziness and vertigo, as well as affected his nervous condition. Also, he pointed out that the migraine headache disability "ke[pt] him from maintaining a job due to his required rest resulting in tardiness and increased absenteeism." Based on the evidence presented, the Board finds that the criteria for a 50 percent rating are not met. The evidence of record does not show that the Veteran has had headaches of such frequency or severity (manifested by very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability) to warrant the maximum rating of 50 percent during the appeal period. The Board acknowledges the examination report and the Veteran's lay statements of records showing that his migraine headaches occurred at least two to four days per week. However, the record also reflects that headaches of an incapacitating nature occur only once a month, forcing him to stay in bed for two days. Further, the evidence does not suggest that the Veteran's migraine headache disability alone was capable of causing or caused severe economic inadaptability. Although the record reflects that he has been unemployed, the examiners determined that the Veteran's headache condition did not impact his ability to work. Notably, even his private clinician in May 2015 attributed his unemployability to "his multiple medical conditions" in the aggregate. No examiner nor clinician has found the Veteran's headaches were of the severity to have 'produc[ed]' or be 'capable of producing' severe economic inadaptability. Pierce, 18 Vet. App. 440 (2004)). As the evidence does not show that the Veteran's disability picture of his migraine headaches more closely approximated the criteria for a rating greater than 30 percent during the appeal period, the Board may not stage his rating. Fenderson, 12 Vet. App. at 125-26. The evidence of record fails to show that the Veteran's migraine headaches cause very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. Therefore, the maximum 50 percent rating is not warranted. The Veteran experiences non-headache symptoms of his migraines such as including nausea, vomiting, sensitivity to light, sensitivity to sound, changes in vision, and sensory changes. "Migraine" is defined as "an often familial symptom complex of periodic attacks of vascular headache, usually temporal and unilateral in onset, commonly associated with irritability, nausea, vomiting, constipation or diarrhea, and often photophobia." Dorland's Illustrated Medical Dictionary, 1166 (32nd ed. 2012). His secondary non-headache symptoms are contemplated by Diagnostic Code 8100. Accordingly, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A rating greater than 30 percent is denied. 2. Entitlement to a disability rating greater than 10 percent before June 3, 2015, for dyspepsia (claimed as GERD/IBS) is denied. 3. Entitlement to a disability rating greater than 30 percent beginning June 3, 2015, for dyspepsia is denied. The Veteran contends that he is warranted a rating greater than 10 percent before May 07, 2018, and greater than 30 percent thereafter, for his dyspepsia for it has worsened. His dyspepsia is currently rated under Diagnostic Code 7399-7346. For the reasons discussed below, the Board grants a 30 percent rating beginning June 2, 2015 for dyspepsia. However, the preponderance of the evidence is against a 60 percent rating during the appeal period. Hyphenated Diagnostic Codes are used when a rating under one code requires the use of an additional Diagnostic Code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the use of Diagnostic Codes 7399 and 7346 reflects that there is no Diagnostic Code specifically applicable to the Veteran's dyspepsia disability and that this disability is rated analogously to hiatal hernia, as they affect similar anatomical functions, occur in similar areas, and manifest similar symptoms, under Diagnostic Code 7346. 38 C.F.R. § 4.20. Under Diagnostic 7346, 10 percent is warranted for hiatal hernia with two or more of the symptoms for the 30 percent rating of less severity. A 30 percent is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. "Considerable," as referenced under the criteria for the 30 percent rating, is defined as "large in extent or degree.' Merriam-Webster's Collegiate Dictionary 267 (11th ed. 2012). A 60 percent is warranted when there are 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. The Veteran's treatment notes of record indicate his history of dyspepsia and dyspepsia, and complaints and treatment for worsening symptoms. The Veteran underwent a VA Esophageal Conditions examination in March 2014 and May 2018, and August 2018, wherein he was consistently diagnosed with dyspepsia. During the March 2014 examination, he reported frequent episodes of epigastric pain, reflux, heartburn, and dyspepsia. He also reported that he had not been to the ER or hospitalized for his condition within the past 12 months. As to whether the Veteran had the following signs or symptoms due to any esophageal conditions (including GERD), the examiner noted that they included persistently recurrent epigastric distress, pyrosis (heartburn), reflux, and mild nausea. The frequency of episodes of nausea was four or more times per year, and the average duration was less than one day. The examiner did not find that the Veteran's symptoms caused considerable impairment of health. "Considerable" is defined as "large in extent or degree." Merriam-Webster's Collegiate Dictionary 267 (11th ed. 2012). Although the Veteran experiences ongoing symptoms, the most probative evidence of record prior to June 3, 2015, does not show that they result in impairment of health of a level of severity that would e accurately described as "considerable." The VA examiner found that his dyspepsia did not impact his ability to work. There is no medical or lay evidence of record describing the impact of the Veteran's dyspepsia on his overall health and well-being prior to June 3, 2015. For these reasons, a rating higher than 10 percent prior to June 3, 2015 is denied. During the May 07, 2018 examination, he reported daily epigastric pain (6/10, pain scale), reflux/heartburn that was worst at night, dyspepsia, and monthly episodes of associated nausea, diarrhea, and vomiting, lasting two days. As to whether the Veteran had signs or symptoms due to any esophageal conditions (including GERD), the examiner noted that they included persistently recurrent epigastric distress, pyrosis, reflux, substernal pain, nausea (four or more times per year, lasting less one to nine days) and vomiting (four or more times per year, lasting one to nine days), that were productive of considerable impairment of health. The examiner stated that the Veteran did not have any other pertinent physical findings, complications, conditions, signs, or symptoms from his dyspepsia. This examination was the basis for the grant of a 30 percent evaluation. Although an effective date should not be "assigned mechanically" as of the date of an examination, there must be a factual basis for choosing an earlier date. Swain v. McDonald, 27 Vet. App. 219, 224 n. 4 (2015). At his June 3, 2015 Board hearing, the Veteran's representative stated that the Veteran's dyspepsia was getting worse. The Veteran testified that he had problems swallowing, that he had chest and shoulder pain, and that his reflux interfered with his sleep and made him cough. Because the Veteran provided examples of worsening of his disability at his hearing, June 3, 2015 is the appropriate effective date for the 30 percent rating. To this extent, the appeal is granted. However, the record does not show that the 60 percent criteria were more nearly approximated during the appeal period. The Veteran's dyspepsia is rated by analogy to hiatal hernia under Diagnostic Code 7346. Because it is rated by analogy, all the objective criteria of the analogous Diagnostic Code will not always be met. Stankevich v. Nicholson, 19 Vet. App. 470 (2006). Significantly, prior to the May and August 2018 examinations, the Veteran had epigastric pain, but no other symptoms listed in the 60 percent criteria: vomiting, material weight loss and hematemesis or melena with moderate anemia. Further, he did not have other symptom combinations productive of "severe" impairment of health. Prior to June 3, 2015, as explained above, the Veteran's dyspepsia did not result in "considerable" impairment of health. Since the 60 percent criteria contemplate "severe," and the 30 percent criteria contemplate "considerable" impairment of health, it is reasonable to conclude that the 60 percent criteria require an impact that is worse than "considerable." Therefore the 60 percent criteria were not met prior to June 5, 2015. In August 2018, the Veteran was afforded another VA esophageal conditions examination. He reported worsening of his disability, to include persistent regurgitation and pyrosis. Addressing the sign or symptoms of said disorders, the examiner noted symptoms, productive of considerable impairment of health, infrequent episodes of epigastric distress, persistently recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, substernal pain, sleep disturbance caused by esophageal reflux (four or more times per year), nausea (four or more times per year, lasting less than one day) and vomiting (four or more times per year, lasting less than one day). The May 2018 and August 2018 examinations noted the addition of vomiting to the list of the Veteran's symptoms, and vomiting is listed in the 60 percent criteria. However, the other types of symptoms listed in the 60 percent criteria indicate a level of severity that is not present in this case. The other symptoms listed include material weight loss "and" hematemesis or melena "with" moderate anemia. 38 C.F.R. § 4.114. None of these symptoms are present. In fact, the record shows consistent weight gain. Additionally, during all three VA examinations, the examiners noted that the Veteran did not have an esophageal stricture, spasm of the esophagus (cardiospasm or achalasia), or an acquired diverticulum of the esophagus. Regarding whether the Veteran had any other pertinent physical findings, complications, conditions, signs, or symptoms related to any conditions diagnosed, the examiners noted none. Therefore, the Veteran did not have "other symptom combinations" that produced severe impairment of health, to meet the 60 percent criteria. Moreover, his daily pain from GERD/IBS has not been shown to impair his health or ability to function. Based on the evidence presented above, the Board finds that the Veteran's symptoms do not more closely approximate a 60 percent rating under during the appeal period. The Board has considered whether separate or increased evaluations are warranted under any other diagnostic codes pertaining to the digestive system that would afford the Veteran a separate and/or higher rating. However, the ratings under diagnostic codes 7301 to 7329, 7331, 7342, 7345 to 7348 inclusive may not be combined with each other. Accordingly, the preponderance of the evidence is not in favor of a higher than 30 percent rating, beginning June 3, 2015. 38 C.F.R. § 4.4114. Therefore, a higher than 30 percent must be denied. 38 C.F.R. § 4.3. REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder disability is remanded. The Veteran has been diagnosed with a right shoulder tear superior glenoid labrum, which he contends is due to service. The Veteran's service treatment records (STRs) are absent complaint, treatment, or diagnosis of any right shoulder disorder. His military specialty (MOS) was a supply clerk. The Veteran's post-service occupation was a mail carrier and later a supervisor. His medical treatment record notes a November 2010 MRI right shoulder slap tear (superior glenoid tear). During a March 2012 General Medical-Pension DBQ, the Veteran reported: "right shoulder pain since several years earlier but did not recall a specific event or onset." The diagnosis of right shoulder slap tear (superior glenoid tear) was noted. In September 2012, the Veteran provided a positive nexus letter from his private treating physician, Dr. N. A. O. V., MD. Dr. N. A. O. V. noted that the Veteran presented with right shoulder problems and reported that he "used to carry heavy loads while in service. He lifted, carr[ied], loaded, and unloaded equipment as part of his daily duties in the supply area; he also carried many of them on his shoulders." She opined that his in-service job duties put stress on his shoulders, and on the column areas, [which] caus[ed] inflammatory changes that promoted degenerative problems in the long term. [Thus], it is at least as likely as not that the right shoulder disorder is service connected." As the Veteran has been diagnosed with a right shoulder slap tear, rather than a degenerative change of the right shoulder, and the clinician did not indicate a familiarity with the Veteran's claim file (including his STRs and post-service treatment records), Board affords this nexus opinion no probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (noting that the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion.). In May 2018, the Veteran was afforded a VA examination to address the possible etiology of the right shoulder disability. The examiner confirmed the diagnosis of right shoulder slap tear (superior glenoid tear) and provided a negative nexus to service. He explained that there were no records of an in-service of a fall or accident to the right shoulder or diagnoses or ailments thereof. It was not until the MRI of November 2010 that there was a showing of the right shoulder disorder. The Board also affords this May 2018 VA medical opinion no probative weight. The examiner relied on the absence of records to form his conclusion and failed to address the Veteran's lay statements of how his injury was incurred. For example, the Veteran reported that he injured his right shoulder from the moving and lifting of heavy equipment in service; not a fall or accident as the examiner indicated. As there is no adequate medical opinion of record, a remand is warranted for a supplemental opinion. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). 2. Entitlement to service connection for a lumbosacral spine disability is remanded. 3. Entitlement to service connection for a cervical spine disability is remanded. The Veteran has been diagnosed with multi-level degenerative change, discogenic disease, and paravertebral myositis of the cervical spine, and lumbar canal and spinal stenosis. He contends that his cervical and lumbar disabilities are a result of his service; specifically, his lifting and moving heavy equipment therein. In a Statement in Support of Claim dated in June 2014, he argues in the alternative that the C-PAP used for his service-connected OSA caused neck and back spasms. Additionally, in a June 2014 private Headache DBQ, the clinician noted that the Veteran had cervical spasms due to his migraine headache disability. In support of his claims, the Veteran provided a September 2012 positive medical opinion from his private clinician, Dr. N. A. O. V., MD. Dr. N. A. O. V. opined that the Veteran's in-service job duties put stress on his shoulders and the column areas causing inflammatory changes that promoted degenerative problems in the long term. "[A]ll of this caused loss of correct alignment and loss of curvature of the cervical, thoracic and lumbar lordosis, consequently putting more stress on one side of the vertebrae than the other and by consequence present disc bulging and herniation with degenerative problems. [Thus,] it is at least as likely as not that the neck and back disorders are service connected." The Board finds this opinion lacking as the clinician failed to address whether the disabilities manifested within a year of service and the effect of his post-service career as a postal carrier on the development of the said disabilities. In May 2018, the Veteran was afforded a VA Back (Thoracolumbar Spine) and Neck (Cervical Spine) Conditions examinations in May 2018. The examiner proffered a negative nexus and explained that there was no evidence of a cervical or lumbar spine condition with onset during service. Additionally, the present findings are changes that can occur as part of the normal aging process. Here too, the Board finds this nexus opinion incomplete. The examiner relied on the absence of a cervical or lumbar disorder in-service. Thus, a supplemental opinion is warranted for an adequate medical opinion, including addressing the theories of entitlement. Barr, 21 Vet. App. 303, 308 (2007). 4. Entitlement to a TDIU before September 30, 2013, is remanded. The Board cannot adjudicate the claim for a TDIU before September 30, 2013, since it is deemed inextricably intertwined with the service connection claims being remanded. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered); Tyrues v. Shinseki, 23 Vet. App. 166, 178 (2009). Accordingly, the matters are REMANDED for the following action: 1. Provide the Veteran's claim file to a qualified clinician so that an examination may be provided addressing the possible etiology of his right shoulder disability. The entire claims file and a copy of this remand must be made available to the examiner for review. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's right shoulder disability manifested during active service or is related to any incident therein. The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such a conclusion. 2. Provide the Veteran's claim file to a qualified clinician so that an examination may be provided addressing the possible etiology of his cervical spine disorder. The entire claims file and a copy of this remand must be made available to the examiner for review. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. The examiner should provide an opinion as to: a. Determine all cervical disorders during the period on appeal. b. Whether it is at least as likely as not (50 percent or greater probability) that any cervical disability manifested during active service or is related to any incident therein; or if arthritis is diagnosed, began within one year of service. c. Whether it is at least as likely as not (50 percent or greater probability) that any cervical disability is proximately due to or the result of his service-connected migraine headache disorder and/or his OSA and the C-PAP machine used therefor. d. Whether it is at least as likely as not that any cervical disability is aggravated (increased in severity beyond the natural progression of the disorder) by his service-connected migraine headache disorder and/or his OSA and the C-PAP machine used, therefor. The examiner is reminded that separate opinions and rationales are required for causation and aggravation. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such a conclusion. 3. Provide the Veteran's claim file to a qualified clinician so that an examination may be provided addressing the possible etiology of his lumbosacral spine disorder. The entire claims file and a copy of this remand must be made available to the examiner for review. A physical examination of the Veteran or telehealth examination is only required if deemed necessary by the clinician. The examiner should provide an opinion as to: a. Determine all lumbosacral disorders during the period on appeal. b. Whether it is at least as likely as not (50 percent or greater probability) that any lumbosacral disability manifested during active service or is related to any incident therein; or if arthritis is diagnosed, began within one year of service. c. Whether it is at least as likely as not (50 percent or greater probability) that any lumbosacral disability is proximately due to or the result of his service-connected OSA and the C-PAP machine used therefor. d. Whether it is at least as likely as not that any lumbosacral disability is aggravated (increased in severity beyond the natural progression of the disorder) by his OSA and the C-PAP machine used therefor. The examiner is reminded that separate opinions and rationales are required for causation and aggravation. Atencio, 30 Vet. App. 74 (2018). The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such a conclusion. 4. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a supplemental statement of the case, and allow the appropriate time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Stevens, 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.