Citation Nr: 21073098 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 13-06 545A DATE: December 7, 2021 ORDER Entitlement to service connection for hypothyroidism as due to exposure to herbicide agents is granted. Entitlement to service connection for an eye disability, to include glaucoma claimed as due to the service-connected diabetes mellitus, is denied. Entitlement to service connection for adrenal gland tumor, to include as due to exposure to herbicide agents, is denied. Entitlement to service connection for tumor neoplasm of the right side, to include as due to exposure to herbicide agents, is denied. REMANDED Entitlement to service connection for colon polyps, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for restrictive lung disease, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for sleep apnea, to include as due to exposure to herbicide agents, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to exposure to herbicide agents, is remanded. FINDINGS OF FACT 1. It is presumed that the Veteran's hypothyroidism is the result of herbicide exposure. 2. An eye disability to include glaucoma was not manifest in service, is not shown to be attributable to service to include as due to exposure to herbicides in service nor is it due to a service-connected disability. 3. Adrenal gland tumor was not manifest in service, is not shown to be attributable to service to include as due to exposure to herbicides in service nor is it due to a service-connected disability. 4. Tumor neoplasm of the right side was not manifest in service, is not shown to be attributable to service to include as due to exposure to herbicides in service nor is it due to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypothyroidism have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for service connection for an eye disability to include glaucoma, have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for service connection for adrenal gland tumor have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for tumor neoplasm of the right side have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from July 1970 to June 1973. Initially, the Board notes that when these issues were before the Board in February 2021 and July 2021, it was determined that further development was needed to include obtaining Social Security Administration (SSA) records and decisions. In July 2021, however, SSA National Records Center sent correspondence to VA that they could not send the medical records requested as such records do not exist and further efforts to obtain them will be futile. For that reason, the Board finds that there are no records to obtain on this matter, that the duty to assist has been satisfied, and that there has been substantial compliance with the prior remand directives. Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Service Connection Service connection may be established for disability resulting from personal injury sustained or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, such as malignant tumors, may be presumed to be service-connected if manifested to a degree of 10 percent disabling or more within one year after separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. The continuity and chronicity provisions of 38 C.F.R. § 3.303(b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as "a substitute way of showing in-service incurrence and medical nexus.") A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Secondary service connection is permitted based on aggravation. Compensation is payable for the degree of aggravation of a nonservice-connected disability caused by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995). Absent affirmative evidence to the contrary, there is a presumption of exposure to herbicides (to include Agent Orange) for all veterans who served in the Republic of Vietnam during the Vietnam Era. See 38 U.S.C. § 1116(f) and 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval, or air service, certain diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even if there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). Of note, the National Defense Authorization Act (NDAA) for Fiscal Year 2021 has added three disorders to the list of diseases presumptively associated with exposure to herbicide agents. Specifically, it amended 38 U.S.C. § 1116(a)(2) to include Parkinsonism, bladder cancer, and hypothyroidism. Here, personnel records show that the Veteran served in Vietnam during the Vietnam Era. Thus, herbicide exposure has been conceded. Hypothyroidism The Veteran appeals the denial of service connection for hypothyroidism. The Veteran claims that his disability is due to service to include exposure to herbicide agents during service. In relation to his claim, the Veteran was afforded a VA examination in August 2017. The August 2017 VA examiner found that there was no evidence that thyroid disease (hypothyroidism) was caused by Agent Orange, nor was it aggravated beyond its natural course by diabetes mellitus type 2, and there was no evidence that the condition began during active duty. In August 2020, the VA examiner opined that the condition claimed was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. The VA examiner stated that the Veteran has hypothyroidism caused by thyroidectomy (surgical ablation of his thyroid gland) in 1979. The examiner reasoned that the current etiology of the hypothyroidism is the thyroidectomy. It was noted that the thyroid gland role is to produce thyroid hormones and when it has been surgically removed lifelong oral thyroid replacement medications is required. There examiner found that there is no evidence that the thyroidectomy was caused by the Veteran's diabetes mellitus. The Board is mindful of the opinions of the VA examiners. Post service records, however, reveal that the Veteran has been diagnosed with hypothyroidism, which is now one of the diseases for which service connection is presumed in veterans who were exposed to an herbicide agent. Herbicide exposure has been conceded. As such, service connection for hypothyroidism is warranted on a presumptive basis and the claim is granted. Eye disability, Adrenal gland tumor and Tumor neoplasm of the right side The Veteran appeals the denial of service connection for an eye disability to include glaucoma, adrenal gland tumor and tumor neoplasm of the right side. The Veteran claims that his disabilities are due to service to include exposure to herbicide agents during service. Alternatively, the Veteran argues that his disabilities are secondary to his service-connected diabetes mellitus. Initially, the Board finds that service connection is not warranted on a presumptive basis. Although the Veteran is shown to have an eye disability, adrenal gland tumor and tumor neoplasm of the right side, the diagnosed conditions are not conditions that are subject to presumptive (herbicide or Agent Orange) service connection pursuant to 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). Thus, service connection for these disabilities on a presumptive basis is not warranted. The Board also finds that service connection for an eye disability, adrenal gland tumor and tumor neoplasm of the right side is not warranted on a direct basis. To that end, service treatment records are negative for any complaints, treatment and/or diagnoses for the eyes, adrenal gland tumor and/or tumor neoplasm of the right side. The Board further notes that malignant tumor is not shown within one year after separation from active duty. The Board has reviewed the service examination reports, VA medical records, VA examinations, and private treatment records of file. These records do not include any competent evidence linking these disabilities to service or any incident therein. Rather, the August 2017 VA examiner opined that the tumor adrenal gland and tumor neoplasm of the right side were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that benign adrenal gland tumors are not presumptive conditions and that there is no evidence in the peer- review literature that Agent Orange causes adrenal gland tumor. He also reasoned that there is no evidence that it had its onset during service. He further found that diabetes does not cause tumor growth and there is no evidence that diabetes aggravated the condition beyond its natural course. It was also noted that the tumor on the right side has been reviewed on another MO as it consists of the adrenal benign tumor (incodentaloma) and there is no evidence that it began during active duty nor was caused and/or aggravated by Agent Orange or diabetes mellitus type 2. During the August 2017 VA examination, the Veteran was diagnosed with primary open angle glaucoma. It was noted that the Veteran's initial VA eyecare began in 1998, and that this condition was first diagnosed in March 2014. The VA examiner opined, therefore, that it was less likely than not that the condition had its onset during the Veteran's active service in the 1970s. The examiner also found that, in a literature review, there is no evidence to suggest herbicide exposure as a direct cause of primary open angle glaucoma, therefore he opined that it was less likely than not related to herbicide exposure during service. The VA examiner stated that diabetes mellitus is known to be a potential risk factor in primary open angle glaucoma. Given the lack of other ocular complications related to diabetes mellitus, however, he opined that it was less likely than not the condition has been aggravated beyond normal progress. Cataract both eyes and choroidal nevus of the right eye unrelated to glaucoma was diagnosed. During the March 2020 VA examination, the VA examiner opined the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner found that choroidal nevus, glaucoma, and cataracts were less likely than not due to herbicide exposure in service. The examiner, however, opined that cataracts were at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran's service-connected condition. The examiner reasoned that diabetes mellitus type 2 was first diagnosed based on the record in March 2004. In the same year, the examiner stated that cataracts were diagnosed on record in August 2004. It was noted that cataracts were diagnosed after diabetes mellitus type 2 and according to the Veteran's age having cataracts at the age of 52 (diagnosis year) is considered young and not age-related. Therefore, the examiner found that early development of cataract is due to diabetes mellitus type 2 rather than previously developed cataract and having it aggravated by diabetes. To the extent that the Veteran has been diagnosed cataracts and the VA examiner found that they are related to his service-connected diabetes mellitus, the Board notes that the Veteran is service-connected for diabetes mellitus type II with bilateral combined cataract. The remaining eyes diagnoses of choroidal nevus and glaucoma, however, have not been shown to be attributable to service or the service-connected diabetes mellitus. Rather, the August 2020 VA examiner opined that choroidal nevus was less likely than not associated with exposure to herbicides during service. It was noted that it is a freckle or like a mole which was benign and most likely would have been there regardless if there was exposure to herbicides or not. The examiner further stated that glaucoma was less likely than not incurred due to exposure of herbicides during service. It was noted the glaucoma was recently diagnosed in 2014, and that herbicide is a chemical and may lead to external or internal eye damage. The examiner further expressed that the damage must be instant and is not something that can progress years later. The examiner also opined that the choroidal nevus and glaucoma were less likely than not due to the service-connected diabetes mellitus type 2. The examiner stated that there is no medical correlation between diabetes and choroidal nevus. There is no correlation of glaucoma to diabetes, however, the examiner stated that "studies only show that occur when Veteran have proliferative + macular edema [and] neovascularization diabetic retinopathy for it to cause glaucoma. Normally neovascular glaucoma/rare case of glaucoma associate with diabetes and usually lead to closed angle glaucoma. Open angle glaucoma are not correlated with diabetes. Hence diabetes type 2 with no diabetic retinopathy does not have an indication and aggravation beyond normal progression by diabetes." With regard to choroidal nevus, the examiner opined that it was less likely than not secondary to diabetes. The examiner reasoned that it is a freckle or like a mole which is benign and most likely would have been there regardless of the diabetes or not. The examiner also stated it was first diagnosed in 2009 and has been stable since 2009, so the condition is not aggravated beyond normal progression by diabetes. The more probative evidence of record is against a showing that the Veteran's disabilities are related to service. For the reasons detailed above, the Board must find against the Veteran's claims for service connection. In making this decision, the Board notes that the Veteran is competent to report symptoms, and the circumstances surrounding such. Although lay persons are competent to provide opinions on observable lay symptoms or conditions, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issues in this case, the etiology of his adrenal gland tumor and tumor neoplasm of the right side falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Here, the Board finds that the medical opinion rendered by the VA examiner is persuasive and assigns it greater probative weight than the lay statements of record. To the extent that the Veteran claims that his adrenal gland tumor is due to claimed participation in Project Shipboard Hazard and Defense (SHAD). The Board notes, however, it was determined that the Veteran did not serve aboard a participating ship during the requisite time frame. The Board further notes that there is no credible evidence showing that pertinent, eye, adrenal gland tumor and/or tumor neoplasm of the right side symptomatology have been recurrent/persistent since service and the Veteran does not allege recurrent/persistent symptoms since service. There is also no showing that adrenal gland tumor and/or tumor neoplasm of the right side were manifest to a compensable degree within one year of service discharge. As such, service connection is not warranted based upon continuity under 38C.F.R. §3.303(b) or presumptively under 38C.F.R. §3.309(a). In sum, the most probative evidence of record preponderates against the Veteran's claims for service connection. The Board has considered the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claims, that doctrine is not applicable. 38 U.S.C. § 5107. REASONS FOR REMAND The Veteran appeals the denial of service connection for colon polyps. The August 2017 VA examiner found that there was no evidence that colon polyps occurred during active duty. He noted that the first polyps were reported in 1995 and though they started to grow slowly it is impossible to state without resorting to mere speculation when they indeed started to grow. The examiner found that diabetes and Agent Orange are not the cause of colon polyps as per peer-reviewed literature. In August 2020, the VA examiner stated that the Veteran was diagnosed with hyperplastic and tubular adenomas polyps (1995 and 2000) and as per literature they are the among the most common polyps. It was stated that they were both diagnosed well before his diagnosis of diabetes that was diagnosed in 2003 and as such the Veteran's colon polyps have not been aggravated beyond their normal natural course by diabetes. Although the examiner notes that the colon polyps were diagnosed well before the diagnosis of diabetes, this reasoning is insufficient and does not address whether the colon polyps are aggravated by diabetes mellitus. As the record is still unclear as to whether the Veteran's colon polyps are aggravated by the service-connected diabetes mellitus another addendum opinion on this matter is needed. The Veteran appeals the denial of service connection for restrictive lung disease. The Veteran argues that he has asbestosis due to his assignment to the boiler room on the U.S.S. Hoel during service. He further expressed that he would use asbestos pads for pillows and seat cushions in the fireroom. He claims that he was exposed to and worked with asbestos every day. During the October 1996 VA examination, it was noted that while in Vietnam the Veteran had an accident which exposed him to extreme heat, and he could only escape through an underwater chute. His eyes and lungs were burned, and he was incapacitated for three days and given oxygen but then had to return to duty. It was noted that, since that time, the Veteran has had some occasional difficulty breathing and most recently has what was diagnosed as sleep apnea. The Veteran was diagnosed with injury by heat and steam October 1972 with injury at that time to the bronchi and lungs. It was also noted that the Veteran suffered from sleep apnea which may be related to his obesity as a result of his thyroidectomy. The August 2017 VA examiner noted that the Veteran has been diagnosed with non-parenchymal restrictive lung disease since 2002. It was stated that he worked in boiler rooms during his active duty and most likely was exposed to asbestosis. It was noted that he was onboard the USS Hoel and worked in the fire rooms for three years but that he did not have a diagnosis of known asbestosis lung disease at that time. The examiner additionally reasoned that the respiratory condition diagnosed was restrictive lung disease, non-parenchymal, was most likely due to obesity. He stated though the Veteran was working in boiler rooms onboard the ship and exposed to significant heat at most likely asbestosis, at that time there was no evidence of pleural plaques nor interstitial lung disease nor lung cancer, and that there was no evidence that the non-parenchymal restrictive condition was caused by or aggravated by Agent Orange or diabetes mellitus. In relation to his claim, another VA opinion was obtained in this matter in August 2020. The VA examiner opined that there is no evidence of a documented pulmonary lung disease, nor lung disease caused by the military service. The examiner, however, stated that the Veteran has a diagnosis of dyspnea, but the etiology is unknown as there has been no full workup done in primary care. The examiner further stated that the workup of the Veteran's dyspnea at that time was less likely pulmonary cause, and that obesity and deconditioning are at least as likely as not causes of the above but there are other causes to be ruled out like cardiac etiology. The Board notes that the evidence shows that the Veteran has dyspnea. While the VA examiner addressed the causation of the Veteran's dyspnea to some extent, the examiner also stated that the etiology was unknown as a full workup had not been done. Furthermore, the record does not contain an opinion that addresses whether the Veteran's dyspnea is aggravated by the service-connected diabetes mellitus. For these reasons, another examination on this matter is necessary for proper adjudication of the claim. The Veteran also appeals the denial of service connection for sleep apnea. The Veteran claims that his disability is due to service to include exposure to herbicide agents during service. Alternatively, the Veteran argues that his sleep apnea is secondary to his service-connected posttraumatic stress disorder (PTSD) and/or diabetes mellitus. In relation to his claim, the Veteran was afforded a VA examination in August 2017. The VA examiner opined that the Veteran's sleep apnea was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner found there was no evidence that the Veteran's obstructive sleep apnea began during active duty though his wife reported longstanding history of snoring and apneas (15 to 20 years). He noted that as per pulmonary, gold standard test for obstructive sleep apnea is polysomnogram, snoring and even apneas are not diagnosis without a sleep study and PSN was completed in 2000. He stated that there is no evidence that diabetes causes or worsens obstructive sleep apnea, and that there is no evidence as per peer-reviewed literature that Agent Orange causes obstructive sleep apnea at that time. During the August 2020 VA opinion, the VA examiner opined that the condition claimed was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. The VA examiner reasoned that he could not find evidence in the MR nor in the literature that the Veteran's obstructive sleep apnea has been caused nor aggravated by his service connected PTSD, there is no evidence in the literature that PTSD causes nor aggravates obstructive sleep apnea. The VA examiner further noted that VA pulmonary specialists, Dr. H and Dr. Z. rendered input on this matter in support of the absence of a nexus between obstructive sleep apnea and PTSD despite few years of recent literature studies listing studies of PTSD and obstructive sleep apnea. It was noted that none have been statistically significant nor have proven a nexus between PTSD and OSA nor aggravation of OSA caused by PTSD. While the VA examiner discussed the input from Dr. H and Dr. Z on this matter, the Board finds that the opinion does not adequately address whether there was aggravation of the obstructive sleep apnea from the service-connected PTSD. Furthermore, the opinion is contradictory as the VA examiner first notes that he could not find evidence in the MR nor in the literature that the Veteran's obstructive sleep apnea has been caused nor aggravated by his service-connected PTSD but then he acknowledges some studies but claims that none have been statistically significant. For these reasons, another opinion on this matter is necessary for proper adjudication of the claim. Lastly, the Veteran also appeals the denial of service connection for GERD. While addressing GERD, the August 2017 VA examiner found that there was no evidence that GERD was diagnosed during active duty and that there was no evidence that Agent Orange and diabetes mellitus type 2 caused GERD or aggravated GERD beyond its natural progression. In August 2020, the VA examiner opined that GERD was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that there was no documented evidence that the Veteran's GERD began nor has been caused by his military duties neither directly nor proximately. The examiner stated that review of the service treatment records does not show complaints of GERD. The examiner concluded that GERD is due to the reflux of stomach acid and that it responded to medication. After review of the record, the Board finds that a sufficient opinion still has not been obtained addressing whether the Veteran's GERD is caused and/or aggravated by his diabetes mellitus. While the August 2017 VA examiner opined that the Veteran's GERD was not aggravated by his diabetes mellitus, a reasoning was not provided in support of the opinion. Furthermore, the examiner expressed that in the case of the Veteran he had no reported hiatal hernia nor delayed stomach emptying on his 2001 endoscopy, the Board notes that the reliance on a 2001 examination is far too remote to properly address this claim. For these reasons, another opinion on this matter is necessary for proper adjudication of the claim. The matters are REMANDED for the following action: 1. Associate with the claims folder updated VA treatment records. 2. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran's colon polyps. The examiner must be provided access to the Veteran's electronic claims file. If, after review of the claims file, the examiner determines that another VA examination is necessary, such must be scheduled, and the Veteran must be notified. The examiner is requested to provide an opinion as to: (a) whether it is at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed colon polyps was caused by or results from his service-connected diabetes mellitus type II; (b) whether it is at least as likely as not (50 percent or greater probability) that the Veteran's service-connected diabetes mellitus has caused any additional medically discernible functional impairment of colon polyps, even if temporary (e.g., a worsening of symptoms beyond the expected baseline level of symptoms). A complete rationale for any opinion should be provided. If an opinion cannot be made without resort to speculation, please state so and include an explanation for that conclusion. 3. Schedule an examination to determine the nature and etiology of the Veteran's restrictive lung disease. The examiner must be provided access to the Veteran's electronic claims file. The examiner is requested to provide an opinion as to: (a) whether it is at least as likely as not (50 percent probability or greater) that any lung disability, diagnosed on examination or in the record to include dyspnea, had its onset in service or is otherwise related to service to include exposure to herbicides during service; (b) whether it is at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed lung disability to include dyspnea was caused by or results from his service-connected diabetes mellitus type II; (c) whether it is at least as likely as not (50 percent probability or greater) that his service-connected diabetes mellitus, resulted in an aggravation of his diagnosed lung disability to include dyspnea (e.g., a medically discernible increase in frequency, duration and/or severity of functional impact, even if temporary, above the degree associated with that expected from his lung disability alone). In doing so, the examiner must address: (1) the September 1992 in services team blast accident, (2) the October 1971 in service diagnosis of hemoptysis, (3) the March 1971 in service complaints and treatment for cold and (4) the October 1996 VA examination diagnosis of injury by heat and steam October 1972 with injury at that time to the bronchi and lungs. A complete rationale for any opinion should be provided. The examiner must not rely solely on the absence of a diagnosis or symptom in service as the basis for a negative opinion. It is also noted that the mere passage of time without treatment is not a sufficient basis for finding that no relationship between a current disability and service exists. Any opinion should be reconciled with the service treatment and personnel records, any post-service diagnoses, lay statements, and testimony of the Veteran. If the lay evidence is rejected, an explanation must be provided. If an opinion cannot be made without resort to speculation, please state so and include an explanation for that conclusion. 4. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran's GERD. The examiner must be provided access to the Veteran's electronic claims file. If, after review of the claims file, the examiner determines that another VA examination is necessary, such must be scheduled, and the Veteran must be notified. The examiner is requested to provide an opinion as to: (a) whether it is at least as likely as not (50 percent probability or greater) that GERD had its onset in service or is otherwise related to service to include exposure to herbicides during service; (b) whether it is at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed GERD was caused by or results from his service-connected diabetes mellitus type II; (c) whether it is at least as likely as not (50 percent probability or greater) that his service connected diabetes mellitus, resulted in an aggravation of his diagnosed GERD (e.g., a medically discernible increase in frequency, duration and/or severity of functional impact, even if temporary, above the degree associated with that expected from his GERD alone). A complete rationale for any opinion should be provided. If an opinion cannot be made without resort to speculation, please state so and include an explanation for that conclusion. 5. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran's obstructive sleep apnea. The examiner must be provided access to the Veteran's electronic claims file. If, after review of the claims file, the examiner determines that another VA examination is necessary, such must be scheduled, and the Veteran must be notified. The examiner is requested to provide an opinion as to: (a) whether it is at least as likely as not (50 percent probability or greater) such disease had its onset in service or is otherwise related to service to include exposure to herbicides during service; (b) whether it is at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed obstructive sleep apnea was caused by or results from his service-connected PTSD; (c) whether it is at least as likely as not (50 percent probability or greater) that his service-connected PTSD, resulted in an aggravation of his diagnosed obstructive sleep apnea (e.g., a medically discernible increase in frequency, duration and/or severity of functional impact, even if temporary, above the degree associated with that expected from his obstructive sleep apnea alone). 6. Thereafter, the AOJ should consider all of the evidence of record and readjudicate the issues on appeal. If the benefits sought are not granted, issue a Supplemental Statement of the Case (SSOC) and allow the Veteran and his representative an opportunity to respond. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.S. Willie 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.