Citation Nr: 21067131 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 17-14 007 DATE: November 3, 2021 ORDER As new and material evidence to reopen the claim of entitlement to service connection for an acquired psychiatric disorder has been received, the appeal as to this matter is granted. The claim of service connection for an acquired psychiatric disorder, diagnosed as unspecified anxiety disorder, is granted. REMANDED The issue of entitlement to service connection for hypertension is remanded. The issue of entitlement to service connection for a right knee disability is remanded. The issue of entitlement to service connection for a left knee disability is remanded. The issue of entitlement to service connection for sleep apnea, claimed secondary to service-connected asthma, is remanded. The issue of entitlement to a rating greater than 30 percent for service-connected asthma is remanded. FINDINGS OF FACT 1. An April 2000 rating decision determined that new and material evidence had not been received to reopen a previously denied for service connection for an acquired psychiatric disorder; although notified of the denial, the Veteran did not initiate an appeal, and no pertinent exception to finality applies. 2. New evidence added to the record since the April 2000 denial relates to an unestablished fact necessary to substantiate the claim of service connection for an unspecified anxiety disorder, and, when considered along with other evidence of record, provides a reasonable possibility of substantiating the claim. 3. Competent, probative evidence demonstrates that the Veteran has a current diagnosis of unspecified anxiety disorder, which as likely as not is attributable to the Veteran's service duties. CONCLUSIONS OF LAW 1. The April 2000 rating decision that determined that new and material evidence had not been received to reopen a previously denied claim for service connection for an acquired psychiatric disorder is final. 38 U.S.C. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. As pertinent evidence received since the April 2000 denial is new and material, the criteria for reopening the claim for service connection for acquired psychiatric disorder are met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 3. With resolution of reasonable doubt in the Veteran's favor, the criteria for service connection for an acquired psychiatric disorder, diagnosed as unspecified anxiety disorder, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1973 to June 1975 This appeal to the Board of Veterans' Appeals (Board) arose from July 2014, April 2016, October 2017, and January 2019 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). Specifically, in the July 2014 rating decision, the RO, inter alia, denied service connection for hypertension and determined that new and material evidence sufficient to reopen a previously denied claim for service connection for inadequate personality, claimed as a nervous condition, has not been presented. The Veteran disagreed with those denials and subsequently perfected an appeal to the Board. (Given the multiple psychiatric diagnoses of record, the Board has recharacterized the claim for service connection for a nervous condition as one for an acquired psychiatric disorder, as set forth above, pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009)). In the April 2016 rating decision, the RO denied service connection for sleep apnea, claimed secondary to service-connected asthma. The Veteran disagreed with the decision and subsequently perfected an appeal of that issue to the Board. In the October 2017 rating decision, the RO, inter alia, denied a rating greater than 30 percent for service-connected asthma, and in the January 2019 rating decision, the RO, inter alia, denied service connection for right and left knee disability. The Veteran timely disagreed with those denials and subsequently perfected an appeal of the issues to the Board. In June 2021, the Veteran testified at a Board hearing before the undersigned Veteran's Law Judge; a transcript of that hearing is of record. The Board also notes that since the claims were certified for appeal to the Board, the Veteran submitted additional medical evidence directly to the Board, which was not accompanied by a waiver of initial consideration by the agency of original jurisdiction (AOJ). In this regard, the Board notes that former 38 U.S.C. § 7105(e) provided for an automatic waiver of initial AOJ review of evidence submitted to the AOJ or to the Board at the time of or subsequent to the submission of a substantive appeal, where the substantive appeal is filed on or after February 2, 2013, and unless the claimant or claimant's representative requests in writing that the AOJ initially review such evidence. Currently, however, 38 C.F.R. § 20.1305(c), as enacted in January 2019 under the Veterans Appeals Improvement and Modernization Act of 2017 (AMA), indicates that when new evidence is submitted, the matter must be referred to the agency of original jurisdiction for review, unless this procedural right is waived by the appellant or representative, or unless the Board determines that the benefit or benefits to which the evidence relates may be fully allowed on appeal without such referral. Notably, although while the AMA did delete 38 U.S.C. § 7105(e), the Public Law specified that Legacy appeals, such as in this case, were to be treated differently than appeals under the AMA. Pub. L. 115-55 § 2(x)(1). Further, the Act provided that changes due to the AMA only applied if a legacy claimant elected to participate in either RAMP or a post-implementation opt-in. As a result, the provisions of 38 U.S.C. § 7105(e) are still in effect when reviewing a legacy appeal; thus, as the substantive appeal in this case was filed after February 2, 2013, and the Veteran has not requested review of the evidence submitted after certification by the AOJ, a waiver of initial consideration by the AOJ is presumed in this case. Petition to Reopen A review of the record shows that the Veteran first sought service connection for a psychiatric condition, claimed as a nervous disorder, in August 1986. That claim was then denied in an October 1986 because the evidence failed to show that the Veteran had a psychiatric disorder for which service connection could be established; rather, it was determined that the Veteran had a personality disorder, which is not a disease for disability compensation purposes. See 38 C.F.R. § 3.303(c) ("congenital or developmental defects, refractive error of the eye, personality disorders and mental deficiency as such are not diseases or injuries within the meaning of applicable legislation"). The Veteran disagreed with the denial of his claim and subsequently perfected an appeal of that issue to the Board. In a November 1987 decision, the Board denied service connection for an acquired psychiatric disability. As that decision was issued prior to the advent of the United States Court of Appeals for Veteran's Claims, it constitutes a final appellate determination as to the Veteran's claim based upon the evidence then of record. See 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. The Veteran then sought unsuccessfully to reopen the previously denied claim for service connection for an acquired psychiatric disorder. Indeed, in an April 2000 rating decision, the RO determined that no new and material evidence had been submitted to reopen the previously denied claim for service connection. The RO notified the Veteran of its determination that same month. However, the Veteran did not initiate an appeal by filing a notice of disagreement within one year. See 38 C.F.R. §§ 20.200, 20.201. Also, no new and material evidence for the claim was associated with the claims file within one of year the denial, and no additional service records have been associated with the claims file at any time, warranting readjudication of the claim. See 38 C.F.R. §§ 3.165(b), (c). Therefore, the April 2000 rating decision is also final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. Thus, the Veteran's claim for service connection for an acquired psychiatric disorder may now be considered on the merits only if new and material evidence has been received since the time of the last final denial. 38 U.S.C. §§ 5108, 7104; Evans v. Brown, 9 Vet. App. 273 (1996); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); 38 C.F.R. § 3.156. Section 3.156(a) of title 38, Code of Federal Regulations provides the following definitions of new and material evidence: New evidence means existing evidence not previously submitted to agency decisionmakers. 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(a). In making the determination of materiality, the "credibility of the evidence is to be presumed." Justus v. Principi, 3 Vet. App. 510, 513 (1992). To determine whether new and material evidence has in fact been submitted, the Board first must compare the evidence submitted since the previous final denial with evidence previously of record. If the newly submitted evidence is that which was not of record at the time of the last final disallowance (on any basis) of the claim, and is not merely cumulative of other evidence that was then of record, it will be considered "new evidence" under 38 C.F.R. § 3.156(a). If the evidence is in fact new, the Board will then consider whether it is also material. In this regard, the Board notes that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 117. When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. See id. at 118, 124 (Lance, J. concurring). Notably, the claim for service connection for an acquired psychiatric disorder was initially denied by the Board in November 1987 because the only psychiatric diagnosis of record was that of inadequate personality, which is not considered a disability for VA compensation purposes. See 38 U.S.C. § 303(c). No additional evidence warranting reopening of the claim was then submitted prior to the April 2000 rating decision. Since the April 2000 rating decision, however, evidence associated with the record shows that the Veteran has been diagnosed with unspecified anxiety disorder. Indeed, the report of an October 2018 VA mental disorders examination records such a diagnosis. The examination report also links the Veteran's anxiety disorder to service. The Board finds that the above-described evidence is "new" in that it was not previously before VA adjudicators, and is not cumulative or duplicative of other evidence. The evidence is also "material", in that it is relevant to the question of the whether the Veteran has a current psychiatric disorder for which service connection may be established. As such, this evidence is new and material within the meaning of 38 C.F.R. § 3.156(a). See Shade, supra. Under these circumstances, the Board concludes that the criteria for reopening the previously denied claim for service connection for an acquired psychiatric disorder are met. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or from aggravation of a preexisting injury suffered or disease contracted in the line of duty. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Generally, to establish direct service connection, there must be competent evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The determination as to whether the elements are met is based on an analysis of all pertinent evidence of record and the evaluation of its competency, credibility, and probative value. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Baldwin v. West, 13 Vet. App. 1, 8 (1999). In adjudicating a claim for VA benefits, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As noted above, the Veteran was afforded a VA mental disorders examination in October 2018, the report of which records a diagnosis of unspecified anxiety disorder. Regarding this evidence, the Board notes that it was generated by VA after the claim was certified for appeal to the Board. The automatic waiver provision of 38 U.S.C. § 7105(e) do not apply to VA generated evidence. See 38 U.S.C. § 7105(e) (providing for initial review by the Board "if the claimant or the claimant's representative . . . submits evidence"). Nevertheless, because this evidence allows for a grant of the benefit sought, it may be reviewed by the Board in the first instance. Specifically, upon review of the record and examination of the Veteran, the October 2018 VA examiner opined that the Veteran's unspecified anxiety disorder was at least as likely as not related to service. As rationale for that opinion, the examiner noted that the Veteran's service treatment records show that he was noted to have "'inadequate personality'" in service and that symptoms associated with anxiety, to include restlessness, insomnia, mild anxiety, and comatic complaint, were described. The examiner also noted the Veteran's complaints related to anxiety since 1987. Based on the Veteran's medical records, presentation, and self-report, the examiner found that the Veteran's current symptoms are consistent with the DSM 5 criteria for unspecified anxiety disorder, which disability is at least as likely as not related to or caused by the symptoms of anxiety and insomnia during service. Here, the Board finds that, with resolution of all reasonable doubt in the Veteran's favor on certain elements of the claim, service connection for an acquired psychiatric disorder, diagnosed as unspecified anxiety disorder, is warranted. Specifically, the October 2020 VA examiner opined in favor of an association between the Veteran's current unspecified anxiety disorder and service. It is clear that the VA examiner considered all relevant evidence before providing the favorable opinion and the Board finds no reason to discount the medical opinion based on the clinician's expertise and qualifications as a medical professional. Reading the opinion as a whole and in the context of the evidence of record, the Board finds that it is of sufficient probative weight to warrant a finding that the Veteran's military service, to include the psychiatric symptoms of anxiety and insomnia noted therein service, likely caused or contributed to the development of his current unspecified anxiety disorder. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). The Board also points out that there is no contrary opinion of record. Thus, given the totality of the evidence discussed above, to particularly include the probative VA medical opinion evidence tending to support the claim, the Board concludes that the Veteran's military service likely caused or contributed to his unspecified anxiety disorder. Accordingly, and with resolution of all reasonable doubt in the Veteran's favor, service connection for an acquired psychiatric disorder, diagnosed as unspecified anxiety disorder, is warranted. REASONS FOR REMAND The Board's review of the claims file reveals that further action by the AOJ on the remaining claims on appeal is warranted. Specifically, with regard to the claim for service connection for hypertension, during his June 2021 Board hearing, the Veteran reported that shortly after discharge from the military, he sought treatment related to high blood pressure at the VA medical center in Dublin, Georgia. The Veteran further reported that the Dublin VAMC referred him to the VAMC in Augusta, Georgia. Here, it does not appear as though any attempt to obtain records from these facilities has ever been taken. Indeed, a review of the record shows that the AOJ contacted the VAMC in Atlanta, Georgia, with a request that that facility provide all records related to treatment of the Veteran beginning in 1977, no similar request has been made to the VAMCs in Dublin and Augusta. Under 38 U.S.C. § 5103A, VA must "make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant's claim for a benefit under a law administered by the Secretary." 38 U.S.C. § 5103A(a)(1); 38 C.F.R. § 3.159(c) (obligating VA to obtain relevant records from Federal department or agency). This duty to assist includes making reasonable efforts to obtain relevant records, including private records, as long as the claimant "adequately identifies" those records and authorizes the Secretary to obtain them. 38 U.S.C. § 5103A(b)(1); Loving v. Nicholson, 19 Vet. App. 96, 101-02 (2005). Given the Veteran's report of treatment related to hypertension at alternative VA facilities shortly after service, the Board finds it necessary to remand the claim of service connection for hypertension for the AOJ to attempt to obtain all records of treatment related to the Veteran, beginning in 1977, from the VAMCs in Dublin and August. See Golz v. Shinseki, 590 F.3d 1317, 1323 (2010) ("[I]f there exists a reasonable possibility that the records could help the veteran substantiate his claim for benefits, the duty to assist requires VA to obtain the records"). Regarding the Veteran's claims for service connection for right and left knee disabilities, the Veteran was afforded a VA knee examination in November 2018. A review of the examination report reflects diagnoses of right knee osteoarthritis and left knee strain. As to the onset of knee symptomatology, the Veteran reported that he injured both knees in service and that symptoms have progressively worsened over time. In this regard, the Board notes that the Veteran's service treatment records the Veteran's complaints of injury to both knees "in the past" and complaints of current knee pain in September 1974. Upon review of the record and examination of the Veteran, the VA examiner opined that it is less likely than not the Veteran's right or left knee condition was incurred in or is otherwise caused by service. As rationale for that opinion, the examiner noted that a 2015 medical examination indicated a normal musculoskeletal evaluation and degeneration of the knees was not shown until "about 35 years after military service." When the VA Secretary provides the claimant with a VA medical examination or otherwise obtains a medical opinion, he must ensure that the examination provided or opinion obtained is adequate for purposes of the determination being made. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A VA medical examination or opinion is adequate if it is "thorough and contemporaneous," considers the veteran's prior medical examinations and treatment, and "describes the disability . . . in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Indeed, a "medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The medical opinion must also "support its conclusions with an analysis that the Board can consider and weigh against contrary opinions." Stefl, 21 Vet. App. at 124; see Nieves-Rodriguez, 22 Vet. App. at 304 ("most of the probative value of a medical opinion comes from its reasoning"). Although the November 2018 VA examiner provided a negative nexus opinion regarding the Veteran's right and left knee conditions, the opinion appears to be based solely on the absence of evidence of knee degeneration until 35 years after service, or 2010. However, the examiner did not take into account the Veteran's lay statements that he has experienced knee symptomatology since service. VA treatment records dates in April 2004 also indicate degenerative joint disease involving the knees. As such, the Board finds the rationale set forth therein to be lacking and cannot conclude that the VA examiner's opinion was based on all evidence of record. See Miller v. Wilkie, 32 Vet. App. 249, 260 (2020) (stating that "[t]he examiner must address the veteran's lay statements to provide the Board with an adequate medical opinion"); Stefl, supra (stating that it is incumbent on the VA examiner to consider all of the relevant evidence before forming an opinion). Accordingly, the Board finds that the November 2018 VA examiner's opinion is inadequate to rely upon for adjudication purposes. See Nieves-Rodriguez and Stefl, both supra. For similar reasons, the Board finds that a positive private medical opinion is also inadequate to rely upon in this case. In this case, in February 2020, the Veteran submitted an opinion from a private clinician who opined that the Veteran's current knee conditions, identified as osteoarthritis of the right knee and chondral malacia patellae of the left knee "were as likely as not caused by stated that the Veteran did frequent running and long marches and that in 1975, he had an injury to his right knee in which his knee was hit by a vehicle. Here, the Board finds that private clinician's opinion is not adequate to support a grant of service connection as the clinician failed to discuss the fact that Veteran's service separation examination report does not document any knee symptomatology. Further, the service treatment records do not disclose any injury to the knee in 1975. Moreover, simply stating that the Veteran did frequent running and long marches is insufficient to link the current diagnoses to service. As noted above, a "medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." Nieves-Rodriguez, 22 Vet. App. at 301. Given that neither the VA nor the private medical opinion is adequate to rely upon for adjudication purposes, the Board finds that the claims for service connection for right and left knee disabilities must be remanded for the AOJ to obtain a new medical opinion, and further examination if necessary, as set forth below. Regarding the Veteran's claim for service connection for sleep apnea, the Veteran has stated his belief that his sleep apnea is secondary to his service-connected asthma. A disability may be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(a), (b). In his VA Form 9, the Veteran reported that he was told by his doctor that his sleep apnea is secondary to his service-connected asthma; this was reiterated by the Veteran during his June 2021 Board hearing. The Board notes that the Veteran has not been afforded a VA examination in connection with his claim for service connection for sleep apnea. The Veteran has also not submitted private medical opinion evidence in support of his claim. However, the Veteran is certainly competent to report on what a physician may have told him. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir 2007) (noting that a layperson is competent to report what he/she was told by a medical professional). The Board also has no reason to doubt the Veteran's credibility in reporting such information. Accordingly, based on this evidence suggesting some connection between the Veteran's asthma and his development of sleep apnea, the Board has determined that the "low threshold" necessary to establish entitlement to a VA medical examination has been satisfied. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); 38 C.F.R. § 3.159(c)(4). Thus, a remand is required for the Veteran to be afforded a VA examination to determine the etiology of his diagnosed sleep apnea, as set forth below. Lastly, with regard to the Veteran's claim for a rating greater than 30 percent for service-connected asthma, the Veteran has reported an increase in the severity of asthma related symptomatology since last examined by VA in August 2017. In support of his assertion, the Veteran provided a copy of a respiratory disability benefits questionnaire, to include results of pulmonary function testing, completed by a private medical provider in February 2020. However, this private medical evidence does not contain all findings necessary to evaluate the severity of the Veteran's asthma under 38 C.F.R. § 4.97, Diagnostic Code (DC) 6602. Although the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted, a new examination is appropriate when there is an assertion and indication of an increase in severity since the last examination. See 38 C.F.R. § 3.159; see also Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). In this case, the lay evidence proffered by the Veteran in his September 2018 VA Form 9 and during the June 2021 Board hearing suggests a possible worsening of the Veteran's hearing acuity. Given the possible increase in severity as well as the length of time since the last examination, the Board finds that remand is necessary for the Veteran to be scheduled for a new and contemporaneous examination to determine the current level of severity associated of the Veteran's service-connected asthma. See Palczewski and Snuffer, both supra; 38 C.F.R. § 3.327(a) (duty to provide a thorough and contemporaneous examination is triggered when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect). The matters are REMANDED for the following action: 1. Obtain from the VAMCs in Dublin and Augusta, Georgia, all outstanding records of evaluation and/or treatment of the Veteran, since June 1975. Follow the procedures of 38 C.F.R. § 3.159 for requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. If records from these facilities are received, the AOJ should review the records and conduct any further development regarding the Veteran's claim for service connection for hypertension required in response thereto, to include scheduling the Veteran for a VA examination, if deemed necessary. 2. The AOJ should contact the VA examiner who performed the VA knee examination in November 2018, if available, and obtain from that clinician an addendum to the examination report. Only arrange for the Veteran to undergo additional VA examination if deemed necessary in the judgment of the individual designated to provide the addendum opinion. The Veteran's claims file, including a copy of this remand, must be made available to the examiner for review in connection with the clarification sought. The examiner should be asked to again review the record, to include the Veteran's lay statements regarding the onset and continuity of knee symptoms, and provide an additional opinion as to whether it is at least as likely as not that the Veteran's right and/or left knee disability is related to service, specifically discussing why or why not the Veteran's reported history of worsening knee symptoms since service supports the Veteran's claim of service connection. If the examiner's opinion regarding nexus remains negative, the examiner should provide an extended rationale for his opinion regarding the likelihood that the Veteran's diagnosed right or left knee disability is related to his active military service, to include the Veteran's reports of having experienced knee symptoms in and since service. 3. Arrange for the Veteran to undergo a VA sleep apnea examination by an appropriate clinician. The Veteran's claims file, including a copy of this remand, must be made available to the examiner for review, and the examination report should reflect consideration of the Veteran's documented sleep apnea history and assertions. Based on examination of the Veteran, and review of all pertinent lay and medical evidence, the examiner should provide an opinion, consistent with sound medical principles, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability), that the Veteran's diagnosed sleep apnea (a) was caused OR (b) is, or has been, aggravated by the Veteran's service-connected asthma. Both causation and aggravation must be addressed. If aggravation is found, the clinician should attempt to quantify the extent of additional disability resulting from aggravation, to include by identifying (to the extent possible), the baseline level of disability prior to the aggravation. In addressing the above, the examiner must consider and discuss all pertinent medical and lay evidence of record, to include the Veteran's statement that his private physician informed him that his asthma had caused or contributed to his sleep apnea. 4. Arrange for the Veteran to undergo a VA examination to evaluate the current severity of his service-connected asthma. To the extent possible, attempts should be made to schedule the Veteran's examination during a flare-up or more active stage of the disability. Following review of the claims folder, an interview with the Veteran, and completion of any testing deemed necessary, the examiner should fully describe the current extent and symptoms associated with the Veteran's service-connected asthma. In so doing, the examiner is asked to: (a.) provide a full description of the disability and report all signs and symptoms necessary for evaluating this disability under the appropriate rating criteria. (b.) Identify all systemic corticosteroids and immunosuppressive medications used, and to the extent possible note the frequency of required use of such medications (and whether any required dosage would be considered high), over 12-month periods from June 2016 (one year prior to the Veteran's filing of his claim for increase) forward. (Continued on the next page) (c.) Estimate the frequency of visits to a physician for required care of asthma exacerbations over 12 month periods since June 2016. In addressing the above, the examiner should address medical evidence of record, to include all evidence of use of corticosteroids, including prednisone, and immunosuppressive medication, and lay reports of record, to include contentions raised at the June 2021 Board hearing that the asthma has increased in severity and that he was receiving injections for treatment of his asthma, but that those were stopped due to concerns with Covid-19. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Neilson, 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.