Citation Nr: 21072646 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 18-21 326 DATE: December 3, 2021 ORDER New and material evidence sufficient to reopen the claim for service connection for a low back disorder has been received and to that extent only the appeal is granted. New and material evidence sufficient to reopen the claim for service connection for posttraumatic stress disorder (PTSD) has been received and it is reopened. New and material evidence sufficient to reopen the claim for service connection for acid reflux secondary to PTSD has been received and to that extent only the appeal is granted. New and material evidence sufficient to reopen the claim for service connection for sleep apnea secondary to PTSD has been received and to that extent only the appeal is granted. Service connection for PTSD is granted. REMANDED Service connection for a low back disorder is remanded. Service connection for acid reflux, to include as secondary to PTSD, is remanded. Service connection for sleep apnea, to include as secondary to PTSD, is remanded. FINDINGS OF FACT 1. A claim for a low back disorder was originally denied in a January 1987 unappealed rating decision finding no evidence of a nexus between non-service back complaints in 1972 and commencement of active duty service in 1974; it was again denied several times thereafter, the last of which being in an unappealed September 2013 rating decision where the RO found no new and material evidence had been submitted. 2. Additional evidence received since September 2013 includes the Veteran's lay statements describing in-service injuries and chronicity of symptoms, which is not cumulative or redundant of the evidence of record at the time of that rating decision, it relates to an unestablished fact necessary to substantiate the claim for service connection for a low back disorder, and it raises a reasonable possibility of substantiating the claim. 3. The issue of PTSD was originally denied in a September 2013 unappealed rating decision finding no diagnosis of PTSD or any other psychiatric disorder; the evidence received since this September 2013 decision includes a private provider's opinion indicating a diagnosis of PTSD related to in-service fear of hostile military activity in Vietnam, which is not cumulative or redundant, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim. 4. The issues of service connection for acid reflux and sleep apnea secondary to PTSD were originally denied in an unappealed September 2013 rating decision on the basis that the Veteran was not service connected for PTSD and based on no evidence of the claimed disorders in service, and no nexus to service. 5. Since September 2013, additional evidence submitted includes a private provider's diagnosis of PTSD medically attributed to fear of hostile military activity in Vietnam as well as medical literature associating PTSD to sleep apnea and acid reflux and, therefore, the new evidence relates to the unestablished facts necessary to substantiate the claims for service connection for acid reflux and sleep apnea, and it raises a reasonable possibility of substantiating these claims. 6. The evidence is at least in equipoise as to whether the Veteran has PTSD attributable to his fear of hostile military activity in Vietnam. CONCLUSIONS OF LAW 1. The unappealed September 2013 rating decision, which denied service connection for a low back disorder, PTSD, acid reflux, and sleep apnea, is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence having been received, the criteria for reopening the previously denied claim of service connection for a low back disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. New and material evidence having been received, the criteria for reopening the previously denied claim of service connection for PTSD have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. New and material evidence having been received, the criteria for reopening the previously denied claim of service connection for acid reflux have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. New and material evidence having been received, the criteria for reopening the previously denied claim of service connection for sleep apnea have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 6. The criteria for service connection for PTSD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304(f), 4.125. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1966 to February 1969, including in the Republic of Vietnam during the Vietnam war. He subsequently served on active duty from November 1973 to September 1986, and again from January 1990 to January 1991. Military records also confirm National Guard service from October 1986 to December 1997. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision by a VA Regional Office (RO). In April 2021, the Veteran testified at a virtual Board hearing. During the hearing the Veteran requested and was granted an additional 90 days within which to submit additional evidence. The allotted 90-day period has elapsed. The Board notes that additional evidence has been associated with the claims file since the March 2018 SOC. However, this appeal involved reopening of claims for service connection, and inasmuch as the claims are being granted, and as none of the reopened claims are being denied in this decision, the Board finds that further delay in the issuance of this decision is not warranted. Additionally, and regarding the issue of service connection for PTSD, the Board is mindful of the Court's holding in Clemons. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (holding that a claimant without medical expertise cannot be expected to precisely delineate the diagnosis of his mental illness; he filed a claim for the affliction that his mental condition, whatever it is, causes him). With this is mind, the Board notes that in August 2019 the Veteran submitted a claim (VA Form 526EZ) for service connection for "depression secondary to IHD/stroke residuals"; and in an October 2019 rating decision the RO denied service connection for depression, including as secondary to service-connected ischemic stroke residuals. Inasmuch as the claim for depression was separately and formally claimed and adjudicated under the AMA system, the undersigned will not address it as part and parcel of the claim for PTSD in this Legacy system decision. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). REOPENING OF CLAIMS A claimant may reopen a finally adjudicated legacy claim by submitting new and material evidence. New evidence is evidence not previously part of the actual record before agency adjudicators. 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). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Regardless of what the RO did, the Board has the jurisdictional responsibility to consider whether it was proper to reopen the claim. The Board will therefore determine whether new and material evidence has been received and, if so, consider entitlement to service connection on the merits. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). 1. New and material evidence sufficient to reopen the claim for service connection for a low back disorder has been received and to that extent only the appeal is granted. The Veteran originally claimed entitlement to service connection for a low back condition in January 1987, which was subsequently denied in a January 1987 rating decision. At that time, the evidence showed that in between periods of active duty, on or around July 1973, the Veteran was in a civilian motor vehicle accident (MVA) where he injured his back. Thus, a nexus to service could not be established. The Veteran did not appeal at that time but attempted to reopen and establish his claim many times throughout the years. The last final rating decision stemmed from the Veteran's April 2012 claim, which was denied in an unappealed September 2013 rating decision finding no new and material evidence had been submitted. In a Special Review rating decision dated in March 2016, the RO purported to reopen the claim for service connection for a low back disorder/compression fracture, L2 with degenerative disc disease and beginning osteoarthritis, and then confirmed and continued the prior denial of service connection. The Veteran appealed the March 2016 rating decision. The relevant evidence at the time of the September 2013 rating decision consisted of service treatment records (STRs); private chiropractic treatment records; other private treatment records; service personnel records; VA medical records; a September 2013 statement from an acquaintance regarding the Veteran's 1972 motor vehicle accident and back complaints; a July 2003 statement from the Veteran regarding the onset of back spasms in 1981; and a copy of a February 1991 letter from a prospective employer regarding the Veteran's back. On review of the record the Board finds that new and material evidence has been submitted since the September 2013 decision. In particular, since the September 2013 decision, the Veteran has submitted correspondence in July 2021 and testified before the Board in regarding various in-service parachuting / jumping duties he believes either caused his current back condition or aggravated any pre-existing condition he may have had from the civilian MVA. He noted that the Army jump school started in 1972, prior to the civilian MVA and that is when his low back pain truly started. He believes that even if he injured his back in the civilian MVA, it was pre-disposed to a back injury because of the in-service parachute jumping. He believed his service "would have aggravated his back faster than versus a regular person who didn't serve." While the Veteran's military records documenting his parachuting duties was already of record at the time of the September 2013 rating decision, the Veteran's testimony describing the chronology of low back pain, when it began, and the number of jumps he took during service was not of record. The Board must presume the credibility of the evidence for the purpose of determining whether it is new and material. Hickson v. Shinseki, 23 Vet.App. 394, 399 (2010); Duran v. Brown, 7 Vet.App. 216, 220 (1994). Thus, in light of the Veteran's post-September 2013 testimony and lay statements, the Board finds new and material evidence sufficient to reopen the claim and to that extent only the appeal is granted. 2. New and material evidence sufficient to reopen the claim for service connection for posttraumatic stress disorder (PTSD) has been received and it is reopened. 3. New and material evidence sufficient to reopen the claim for service connection for acid reflux secondary to PTSD has been received and to that extent only the appeal is granted. 4. New and material evidence sufficient to reopen the claim for service connection for sleep apnea secondary to PTSD has been received and to that extent only the appeal is granted. In April 2012, the Veteran filed a claim seeking entitlement to service connection for PTSD and for acid reflux and sleep apnea, both claimed as secondary to PTSD. These claims were denied in an unappealed September 2013 rating decision mainly because the Veteran did not have a diagnosis of PTSD or any other psychiatric disorder and, therefore, the secondary claims were also not possible. The RO also considered and denied the acid reflux and sleep apnea claims on a direct basis finding no nexus to service. In a Special Review rating decision dated in March 2016, the denials were continued on the same bases. The Veteran appealed the March 2016 rating decision. The relevant evidence at the time of the September 2013 rating decision consisted of STRs; a May 2012 statement from the Veteran describing his experiences in Vietnam and subsequent mental health; a September 2013 statement from an acquaintance regarding the Veteran's hypervigilance and impaired sleep; VA medical records dating from 2011 to 2012, in which providers identified sleep apnea as among the Veteran's active problems and noted that the Veteran "use c-pap at 10 cm for OSA from Kaiser"; Kaiser Medical Records dating from 2009 to 2012, which document the Veteran as suffering from gastritis and sleep apnea; the report of a September 2011 VA Heart Conditions examination, in which the examiner noted that the Veteran had obstructive sleep apnea; a February 2009 Sleep Study Report; the report of a September 2013 VA PTSD examination, in which the examiner acknowledged the Veteran's Vietnam war zone stressor but said that the Veteran did not meet full criteria for PTSD; and VA medical records dating from 2011 to 2012, including the report of a December 2011 positive screen for PTSD. Since September 2013, the Board finds new and material evidence has been submitted. In particular, a January 2019 VA examination report notes a "history of PTSD" as well as an April 2021 VA positive PTSD screen. In May 2021, moreover, the Veteran provided a private psychologist's DBQ noting a diagnosis of PTSD "due to the traumatic stressors [the Veteran] experienced while in Vietnam." The Veteran has also submitted internet articles and medical treatises, received in July 2021, pertaining to the relationship between PTSD, acid reflux, and sleep apnea. Thus, although not dispositive, in light of the medical opinions pertaining to PTSD and the relationship with acid reflux and sleep apnea, the Board finds the evidence is new and material as it raises a reasonable possibility of substantiating the claim. As such, these claims are reopened, and to that extent the appeals are granted. SERVICE CONNECTION 5. Service connection for PTSD is granted. Having reopened the claim of service connection for PTSD based on new and material evidence, the Board has reviewed the underlying claim for service connection de novo, based on the whole record. For the reasons that follow, the Board finds that a grant of service connection for PTSD is warranted. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. "To establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). For a grant of service connection, the diagnosis of a mental disorder must be made in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). 38 C.F.R. § 4.125(a); see also Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020) (holding that with respect to psychiatric disabilities VA has expressly limited compensation to disabilities conforming to a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis and the Court lacks jurisdiction to review the Secretary's decision to require such a diagnosis as set out in the schedule of ratings). Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As stated before, the Veteran contends that he has PTSD, and that it is related to his wartime experiences in Vietnam. Effective July 13, 2010, 38 C.F.R. §3.304(f) was amended to reduce the evidentiary burden of establishing a stressor when it is related to a fear of hostile military or terrorist activity. See 75 Fed. Reg. 39843-01 (July 13, 2010), codified at 38 C.F.R. §3.304(f)(3). The amendment provides that if a stressor claimed by a veteran is related to the veteran's fear of hostile military activity, and a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor, as long as the claimed stressor is consistent with the places, types, and circumstances of the veteran's service and there is no clear and convincing evidence to the contrary. Id. "Fear of hostile military activity" is defined to mean that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The list of examples of such an event or circumstance specifically includes attack upon friendly military aircraft, vehicle-imbedded explosive devices, and incoming artillery, rocket, or mortar fire. Thus, the pertinent inquiries here are (1) whether the Veteran's claimed stressor(s) are related to a fear of hostile military activity, (2) whether there is evidence that a VA psychiatrist or psychologist can confirm that the claimed stressor is adequate to support a diagnosis of PTSD, and (3) whether or not the claimed stressor(s) is consistent with the places, types, and circumstances of the veteran's service with no clear and convincing evidence to the contrary. With regard to the Veteran's claimed stressor(s), the Veteran has been relatively vague and only indicated wartime exposure in Vietnam and feeling as though he would die while stationed there, that he experienced incoming fire, that he lost friends over there, and that he saw wounded and "carnage." His personnel records confirm his presence in Vietnam from February 1968 to February 1969 and there is nothing in the record that would contradict the Veteran's testimony that he generally would have been exposed to wartime experiences. Thus, under the provisions of 38 C.F.R. §3.304(f)(3), the Board finds that the Veteran's claimed stressors are related to a fear of hostile military activity that are consistent with the circumstances of his service with no clear and convincing evidence to the contrary. Rather, the conflicting evidence of record here is whether his claimed stressors have been found sufficient to support a diagnosis of PTSD. The Veteran's STRs do not contain any specific complaints, treatment, or diagnosis related to a psychiatric disorder. Decades after service, in December 2011, a PTSD screen done by VA during the Veteran's initial presentation for healthcare was positive. Additionally, in a statement dated in April 2012, a longtime friend of the Veteran stated that the Veteran would often visit her and her husband and stay overnight. She said that the Veteran "rarely had an undisturbed night's sleep" and sometimes cried out unintelligible words or sounds and did not look rested the following mornings. She also recalled that the Veteran startled easily, always sat facing the door so no one could creep up on him, always appeared to be "listening" for something, and disliked any loud sudden noises. In September 2013, the Veteran was afforded a VA PTSD examination. During the examination the Veteran reported that he went to Vietnam fearing he would die, and that he saw wounded, dying and carnage while serving there and was subjected to enemy incomings. According to the examiner, who acknowledged that the Veteran's Vietnam war experiences stressor was sufficient to support a diagnosis of PTSD, but the Veteran's symptoms did "not meet full criteria for PTSD." Additionally, VA PTSD screens in July 2016 and July 2017 were also negative. A VA Agent Orange Database examination in January 2019, the examiner remarked that there was a history of PTSD, and that the Veteran was "currently reporting anxiety, nervousness." Thereafter, the Veteran was afforded another VA PTSD examination in September 2019. During the examination the Veteran reported that he lost three friends to combat in Vietnam. The examiner noted that the Veteran did not have a history of receiving psychiatric treatment before, during or after military service. The examiner also noted that the Veteran had been examined by VA in 2013, and that the Veteran did not then meet the criteria for PTSD. The examiner then averred that the Veteran "continues to not meet criteria for any DSM psych condition at this time." The only symptom identified on the report was anxiety. Thereafter, a VA PTSD screen in April 2021 was positive; and in April 2021 the Veteran testified that that he experienced incoming enemy fire, saw a lot of carnage, and was in fear for his life while in Vietnam. In June 2021 the Veteran submitted the report of a Telephone Visit Adult Psychiatry Initial Assessment that he had with a Kaiser Permanente psychologist (Dr. J.A.G.) in May 2021. In her report Dr. J.A.G. referred to an April 2021 LCSW note that the Veteran "reports on-going symptoms related to PTSD," but this note is not in the claims file. Dr. J.A.G. averred that the Veteran complained of PTSD symptoms during her consult, "including recurrent memories/thoughts, distressing dreams, flashbacks, hypervigilance, avoidance, exaggerated startle response and psychic numbing." Dr. J.A.G. added the Veteran "reported that he is unable to shake the memories of his time in Vietnam (went in 2 weeks after he graduated high school)." The Veteran also submitted the report of a Psychological Evaluation that was done by another private psychologist (Dr. T.F.) in May 2021. In conjunction with the examination Dr. T.F. completed the latest VA DBQ PTSD [DSM-5] form (released in March 2021), and in the specified section on the form Dr. T.F. provided a current diagnosis of PTSD and the ICD code. In an accompanying narrative report Dr. T.F. informed that the examination was conducted via Telehealth due to Covid-19 concerns; but said that he was able to see the Veteran clearly and fully appreciate all nonverbal cues, mannerisms, and manifestations displayed by the Veteran in a manner on par with an in-person examination. Dr. T.F. added that he had reviewed all of the records provided from the Veteran's claims file, including all of the Veteran's VA treatment records, and performed a thorough review of the Veteran's medical history. Dr. T.F. noted that the September 2013 VA examiner did not return a diagnosis of PTSD but maintained, "this is inconsistent with what the Veteran was reporting at that time and the boxes checked by the examiner do not reflect what the Veteran or [witness] were reporting in their personal statements prior to the examination." According to Dr. T.F., the evidence at the time of the past examination and the current evidence is consistent with PTSD symptoms. Dr. T.F. discussed the Veteran's war experiences, including the wounded, dying and carnage that the Veteran saw and the "constant terror and stress" that the Veteran felt while serving in Vietnam. Dr. T.F. also discussed the Veteran's current symptoms, including the Veteran's report of feeling emotionally dead, alone, and unable to express loving emotional feelings with loved ones. Dr. T.F. also discussed the test battery that he administered. He then asserted that the Veteran's PTSD was "due to the traumatic stressors [the Veteran] experienced while in Vietnam." Dr. T.F. elaborated: He reported symptoms consistent with PTSD and has sought treatment for these symptoms. The contents of his nightmare center around themes associated with Vietnam such as being drafted again to go to Vietnam. He noted also a nightmare related to a rat chewing on his face which was tied to an incident where a rat had attacked the face of someone in the same location he was sleeping while in Vietnam. In sum, while the Veteran clearly served in Vietnam and reports various in-service wartime related stressors, the evidence is in conflict as to whether he meets the diagnostic criteria of PTSD in accordance with the DSM-5. The Board acknowledges that the Veteran's claimed in-service stressor pertains to fear of hostile military activity consistent with his Vietnam service and, therefore, can be presumed under the provisions of 38 C.F.R. § 3.304(f)(3). Under that provision, however, it must be a VA psychiatrist or psychologist (as opposed to a private provider) that confirms that the claimed stressor is adequate to support a diagnosis of PTSD. Id. In that regard, the Board notes that while VA examiners in 2013 and 2019 each stated the Veteran's symptoms did not meet the full criteria for a diagnosis of PTSD, the examiners did find that the Veteran's reported stressors would be adequate to support a diagnosis of PTSD. The Veteran has since been diagnosed with PTSD, albeit by a private provider, associated with those in-service stressors. At a minimum, the Board finds the evidence in equipoise. As such, the Veteran is entitled to the benefit of the doubt and a grant of service connection for PTSD is appropriate. REASONS FOR REMAND 1. Service connection for a low back disorder, claimed as back pain is remanded. As outlined above, the Veteran's low back claim is complicated because in between periods of service it is well documented that the Veteran was in a civilian MVA on or around 1972, which included a back injury. The Veteran contends that either he has a back injury that was already well established prior to this MVA due to his military duties or, alternatively, any back disability incurred as a result of that MVA was aggravated due to his military duties, which include parachute jumping and long hours sitting in uncomfortable positions as a pilot. Preliminarily, and regarding the contention of aggravation, VA regulations provide that a veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service. See 38 C.F.R. § 3.304(b). The burden then falls on VA to rebut the presumption of soundness by: (1) clear and unmistakable evidence that the veteran's disability preexisted service; and (2) clear and unmistakable evidence that the condition was not aggravated by service. Id.; see also Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In this case, while there is evidence that the Veteran was involved in a motor vehicle accident and treated for back complaints in October 1972, a few years after his 1969 separation from the U.S. Army, his actual entrance examination does not indicate any back abnormalities. That is, prior to entrance into his second period of service, in July 1973, there is a report of medical history indicating, "Wore back support, Oct-Dec 72, due to automobile accident, hasn't worn it since; no comp, no seq. (See Ortho. Consult)." The respective record of this event is not in the claims file. In other words, there are no records, dated in 1972, in the claims file. His November 1973 entrance examination, moreover, does not indicate any back abnormalities. Thus, for purposes of service connection, the Veteran is entitled to the presumption of soundness. It is worth noting that the Air Force took extra steps to ascertain whether the Veteran had a back disorder during its 1973 processing of his enlistment. The November 26, 1973 examination included a same day referral to the Orthopædic Clinic with the following remarks: "navigator trainee with a history of a compression fracture of vertebrae in auto accident in Oct 72. Wore back brace until Dec 72. No problem since." Whereupon, on November 26, 1973, the Orthopædic specialist responded that there was "no evidence of previous injury or residuals clinically." Additionally, x-rays of the lumbar spine on November 26, 1973 advise: "No Significant Abnormality Noted." The Veteran himself also avers, regarding his entry into the Air Force, that his "injuries pretty much healed up totally at that time. Otherwise, they would not have cleared me for flight duty. That's the way I understand it." See Board Hearing Transcript, p. 11. See also representative's clarification, "I would contend that you know, what [the Veteran] said is that what he had was an acute injury prior to service that healed but once he got into the Air Force, because of his duties it--the wear and tear created a disability for him that he now has." Board Hearing Transcript, p. 12. In any case, it has been the Veteran's contention that regardless of whether he had a pre-existing back injury his in-service duties were far more significant and either the cause of his current back condition or at a minimum an aggravating factor. He testified as to landing wrong in various parachute jumps due to terrain or other obstacles, and long hours sitting as a pilot that caused chronic back pain. In light of this unusual medical history, the Board cannot adjudicate the claim without a VA examination to reconcile the complexities of the case. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In particular, an examiner is required to comment on the nexus of any back condition found, whether it is due to the civilian MVA versus the in-service parachuting and/or pilot duties and to the extent the Veteran had any residuals of the MVA, whether such residuals were aggravated in service. Additionally, it appears that there may be extant relevant private treatment records. See VA medical records dated in July 2021, which advise that the Veteran's request for additional private chiropractic treatment had been approved. Accordingly, the claims file should be updated before the examination is done. 2. 3. Service connection for acid reflux and sleep apnea, to include as secondary to PTSD is remanded. As stated before, the Veteran is requesting service connection for acid reflux and sleep apnea secondary to his PTSD. There is no record of any complaints, diagnosis, or treatment for acid reflux or sleep apnea during service, however, post-service medical records show that the Veteran presently suffers from acid reflux and sleep apnea. Additionally, the Veteran has submitted articles/medical treatises regarding the relationship between PTSD and acid reflux, and PTSD and sleep apnea. As the Veteran is now service connected for PTSD, he should be afforded a VA examination regarding his claims for service connection for sleep apnea and acid reflux secondary to PTSD. McLendon, 20 Vet. App. 79 (2006). The matters are REMANDED for the following action: 1. Take appropriate action to obtain all extant private chiropractic treatment records. Document all efforts taken to obtain these records and all responses. Associate all located records with the claims file. 2. After any outstanding records are obtained, to the extent possible, schedule the Veteran for a VA examination regarding the claim for service connection for a current back disorder. The examiner must review the claims file and note that the claims file review took place. The examiner is asked to provide a response to the following: (a.) Provide the diagnos(es) for all of the Veteran's back complaints. NOTE: If a diagnosis cannot be provided but there nonetheless is pain that causes functional impairment of earning capacity, then the condition should be considered a "disability" for VA purposes. (b.) For each current back disability, opine as to whether it is at least as likely as not that it i. began during the Veteran's May 1966 - February 1969 active-duty service in the Army; or, during the Veteran's November 1973 - September 1986 active-duty service in the Air Force; or, during the Veteran's January 1990 - January 1991 service in the Air Force, in light of the Veteran's description of in-service jumping and piloting duties and the in-service complaints of back pain found within the service treatment records. The examiner is asked to further reconcile whether any back condition found clearly and unmistakably preexisted service and clearly an unmistakably was not aggravated in service in light of the evidence of a 1972 civilian MVA. The examiner is informed that "clearly and unmistakably" is an onerous standard meaning the evidence should be "undebatable." A discussion of the facts and the medical principles involved will be of considerable assistance to the Board. The examiner must specifically address the fact that the Veteran conducted parachute jumps during his enlistment in the U.S. Army and now says that his back pain began during that time. The examiner must also address the evidence of back pain documented in the Veteran's active-duty Air Force STRs and consider the Veteran's assertion that a current back disorder is related to long hours in uncomfortable pilot's seating in aircraft during that time. All conclusions or opinions offered must be accompanied by a complete medical rationale, citing to established medical principles and relevant medical evidence, such as examination findings, service records, VA and private treatment records, or other pertinent evidence in the record to support the conclusions reached. If the examiner concludes that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so should be provided. 3. Schedule the Veteran for a VA examination regarding the issues of service connection for sleep apnea and acid reflux. The examiner must review the claims file and note that the claims file review took place. For each claimed disorder (acid reflux and sleep apnea), the examiner is asked to provide a response to the following: whether the disorder at least as likely as not (a.) began during active-duty service; or (b.) is related to some incident of the Veteran's active-duty service, to include the circumstances of the Veteran's service in the Vietnam war zone; or (c.) is caused or aggravated by the Veteran's service-connected PTSD disability. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board. In formulating the requested opinion, the examiner must particularly address the medical treatises in the claims file regarding the relationship between PTSD and acid reflux, and PTSD and sleep apnea. (Continued on the next page) The examiner must also discuss the conditions of the Veteran's service in Vietnam and consider where there is a relationship between the hardships of that service and his currently presenting acid reflux and sleep apnea. 4. After completion of all the above directives and any other necessary action, re-adjudicate the claims, taking care to address all the evidence since the March 2018 SOC. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Childers, Phyllis 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.