Citation Nr: 21006989 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 16-27 243 DATE: February 8, 2021 ORDER The appeal as to whether new and material evidence has been received to reopen service connection for a disability manifested by sleep impairment, to include paroxysmal nocturnal dyspnea (PND) is granted. Entitlement to an initial rating of 20 percent and no higher for radiculopathy of the right lower extremity is granted subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial rating higher than 10 percent for radiculopathy of the left lower extremity is denied. Entitlement to a rating higher than 10 percent for painful movement of the right knee is denied. Entitlement to a separate rating of 20 percent and no higher for frequent episodes of “locking” and effusion into the joint in the right knee is granted subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating higher than 10 percent for spondylolisthesis is denied. REMANDED Entitlement to a rating higher than 10 percent for asthma prior to May 5, 2015 is remanded. Entitlement to a rating higher than 30 percent for asthma from May 5, 2015 is remanded. Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD), to include depressive disorder, is remanded. Entitlement to service connection for a disability other than PTSD manifested by sleep impairment, to include PND is remanded. FINDINGS OF FACT 1. In a January 2005 rating decision, service connection for insomnia was denied; the Veteran began but did not timely perfect an appeal of that decision, and no new and material evidence was received within the appeal period. 2. Evidence received since the January 2005 rating decision is new, relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a disability manifested by sleep impairment, and raises a reasonable possibility of substantiating the claim. 3. Resolving doubt in the Veteran’s favor, the Veteran’s radiculopathy of the right lower extremity is manifest by moderate incomplete paralysis. 4. The Veteran’s radiculopathy of the left lower extremity is manifest by no more than mild incomplete paralysis. 5. The Veteran’s right knee disability is manifest by painful motion. 6. The Veteran’s right knee disability is manifest by frequent episodes of locking, pain, and effusion into the joint. 7. The Veteran’s spondylolisthesis is manifest by painful motion. CONCLUSIONS OF LAW 1. In a January 2005 rating decision, service connection for insomnia was denied the Veteran did not timely perfect an appeal of that decision, and no new and material evidence was received within the appeal period. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103. 2. Evidence added to the record since the January 2005 denial is new and material, and the claim for entitlement to service connection for a disability productive of sleep impairment is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for a disability rating of 20 percent and no higher for radiculopathy of the right lower extremity have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8520. 4. The criteria for a disability rating in excess of 10 percent for radiculopathy of the left lower extremity have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code (DC) 8520. 5. The criteria for a rating in excess of 10 percent for residuals of right anterior cruciate ligament reconstruction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5260. 6. The criteria for a separate rating of 20 percent and no higher for residuals of right anterior cruciate ligament reconstruction have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5258. 7. The criteria for a rating in excess of 10 percent for spondylolisthesis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5259. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 2001 to September 2004. These matters come before the Board of Veterans’ Appeals (Board) on appeal from March 2015 and January 2016 rating. A July 2019 Board decision remanded the issues of entitlement to a higher rating for right and left lower extremity radiculopathy, entitlement to a higher rating for a right knee disability, and entitlement to a higher rating for a back disability; dismissed claims of service connection for insomnia and depression; denied entitlement to a rating higher than 10 percent for asthma prior to May 5, 2015; and assigned a rating of 30 percent and no higher for asthma from May 5, 2015. The Board finds there has been substantial compliance with its remand directives for the claims decided herein. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran appealed the July 2019 Board decision to the United States Court of Appeals for Veterans Claims (Court). In July 2020, the Court issued an order granting a Joint Motion for Remand (JMR), which served to vacate the contested portions of the July 2019 Board decision. 1. The appeal as to whether new and material evidence has been received to reopen the claim of service connection for a disability manifested by sleep impairment, to include PND It is necessary to decide whether the claim can be reopened before the Board can adjudicate it on its merits. The Veteran implicitly contends that she has submitted new and material evidence sufficient to reopen a claim of entitlement to service connection for a disability manifested by sleep impairment, to include insomnia. To prevail on a direct service connection claim, 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 in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection for insomnia was initially denied by a January 2005 rating decision on the grounds that insomnia is not a disability, and the evidence of record fails to show that a disability has been clinically diagnosed. A timely appeal was begun but was not perfected, and new and material evidence was not received within the one-year appeal period. As such, the decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103. Since the last final denial in January 2005, VA has received an April 2014 private treatment record noting an impression of PND, or paroxysmal nocturnal dyspnea, as well as July 2020 correspondence in which the Veteran’s representative argues that the Veteran’s claim for insomnia encompasses PND. The Board agrees that, as the Veteran is a lay person who is not expected to be able to diagnose her own disability, her claim for insomnia encompasses any disability manifested by sleep impairment, to include PND. Clemons v. Shinseki, 23 Vet. App. 1 (2009); See also Brokowski v. Shinseki, 23 Vet. App. 79 (2009). The additional evidence is new, as it was not previously of record and considered at the time of the most recent final denial in January 2005. The evidence is relevant to the existence of a current disability manifested by insomnia. The evidence thus relates to an unestablished fact necessary to substantiate the Veteran’s claim and raises a reasonable possibility of establishing the claim. See 38 C.F.R. § 3.156. Shade v. Shinseki, 24 Vet. App. 110 (2010). Therefore, the evidence is new and material. Such new and material evidence having been received, the claim of entitlement to service connection for a disability manifested by sleep impairment is reopened. See 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Increased Rating Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Evaluation of a service-connected disorder requires a review of the veteran’s entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to the veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that 38 C.F.R. § 4.59 applies to disabilities other than arthritis). However, painful motion alone is not a functional loss without some restriction of the normal working movements of the body. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. Id.; Esteban v. Brown, 6 Vet. App. 259 (1994). 2. Entitlement to an initial rating higher than 10 percent for radiculopathy of the right lower extremity 3. Entitlement to an initial rating higher than 10 percent for radiculopathy of the left lower extremity The Veteran contends that she is entitled to a higher rating because of her radicular pain. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8620 and 8720.). Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The maximum rating which may be assigned for neuritis not characterized by organic changes will be moderately severe incomplete paralysis for sciatic nerve involvement. See 38 C.F.R. § 4.123. Resolving doubt in the Veteran’s favor, the Veteran’s radiculopathy of the right lower extremity is best characterized as moderate. Although the VA examiners have consistently described the incomplete paralysis of the right sciatic nerve as mild, the April 2019 VA examination noted moderate constant pain in the right lower extremity, moderate paresthesias and/or dysesthesias in the right lower extremity, and moderate numbness in the right lower extremity. The examiner indicated that the history given by the Veteran showed moderate symptoms, although the objective evidence upon examination that day was mild. The Veteran has reported in lay statements during examination and in the February 2016 Notice of Disagreement (NOD) that her radiculopathy makes it painful to sit or stand for extended periods, and that she cannot twist and turn. The Board notes that the Veteran also attributed difficulty with movement, sitting, and standing to her service-connected low back and right knee disabilities. Although objective testing on examination consistently characterized the Veteran’s radiculopathy of the right lower extremity as mild, lay statements describing symptoms during periods of flare-up are for consideration. Because the April 2019 examiner indicated that during at least some periods, perhaps periods of flare-up, the symptoms described by the Veteran are moderate, the Board will resolve doubt in the Veteran’s favor and find that the Veteran’s radiculopathy of the right lower extremity is consistent with moderate incomplete paralysis of the sciatic nerve. This level of impairment corresponds to a 20 percent rating. A rating higher than 20 percent is not available because the VA examinations of record consistently show normal reflex exams, sensory exams, and strength testing, which means that the Veteran’s symptoms are wholly sensory. Therefore, the Board will assign a rating of 20 percent and no higher for radiculopathy of the right lower extremity. The radiculopathy of the left lower extremity is best described as mild. Although the Veteran reported in her February 2016 NOD that her radiculopathy of the left lower extremity prevented her from twisting or turning and bending over, and caused difficulty in toileting, sitting, and standing, it is not clear that this impairment is due to the radiculopathy of the left lower extremity as opposed to her other disabilities. Although the Veteran is competent to report her experiences, as a lay person she is not competent to determine whether her difficulty with movement or toileting is due to radiculopathy of the left lower extremity as opposed to other disabilities. The Veteran has also attributed difficulty with sitting and standing to her service-connected right knee disability. The severe level of functional impairment described in the February 2016 NOD is inconsistent with the symptoms and impairment shown by the four VA examinations of record. Even when the April 2016 examiner took the historical symptoms reported by the Veteran into her account, her left lower extremity radiculopathy symptoms have never been described as anything more than mild. In fact, the Veteran’s radiculopathy of the left lower extremity is so mild that the June 2019 and January 2020 examinations found that the left sciatic nerve was normal and that there were no radicular symptoms in the left lower extremity. Her left lower extremity has consistently been found to have normal reflex and sensory examinations, as well as negative straight leg raising tests. The most probative evidence of record thus suggests that the Veteran’s radiculopathy of the left lower extremity cannot be described as more than mild. Entitlement to an initial rating higher than 10 percent for radiculopathy of the left lower extremity is thus denied. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to a rating higher than 10 percent for painful motion of the right knee 5. Entitlement to a separate rating of 20 percent and no higher for meniscal tear in the right knee The Veteran contends that she is entitled to a higher rating because of severe pain. There are several DCs that relate to the knee. Limitation of flexion is governed by DC 5260. Under DC 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Even if a veteran does not have limitation of motion of the knee meeting the criteria for a noncompensable evaluation under DC 5260 or 5261, a separate evaluation may be assigned if there was evidence of full range of motion “inhibited by pain.” Lichtenfels v. Derwinski, 1 Vet. App. 484, 488 (1991). As 38 C.F.R. § 4.59 is not limited to arthritis, painful motion may result in a compensable rating for cases in which the Veteran does not have arthritis. Recurrent subluxation or lateral instability is rated under DC 5257. Slight recurrent subluxation or lateral instability is assigned a 10 percent rating. Moderate recurrent subluxation or lateral instability is assigned a 20 percent rating. Severe recurrent subluxation or lateral instability is assigned a 30 percent rating. 38 C.F.R. § 4.71a, DC 5257. A 20 percent rating is assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 8 C.F.R. § 4.71a, DC 5258. The Veteran’s right knee disability was initially granted in January 2005 under DC 5260, which relates to limitation of flexion. In a February 2017 rating decision, the Agency of Original Jurisdiction (AOJ) reduced the rating to noncompensable effective October 26, 2016, and changed the DC to 5257, which relates to instability. It is unclear why the DC was changed. The July 2019 Board decision found that the reduction was improper, and discussed the Veteran’s report of pain during flare-ups and when walking long distances. A September 2019 rating decision enacted the July 2019 Board decision by restoring the 10 percent rating for the right knee, and continued to use the DC 5257. Because the 10 percent rating has clearly been assigned due to painful motion, the Board concludes that DC 5260 is the most appropriate DC to rate the Veteran’s disability. The most limited range of motion demonstrated by the record is an April 2019 VA examination finding that during flare-ups, the Veteran’s range of motion is limited to 80 degrees of flexion. 80 degrees of flexion does not approach the limitation of 45 degrees that would be required for a compensable rating for limitation of flexion, much less the limitation of 30 degrees required for a rating higher than 10 percent. As noted above, although the Veteran wears a knee brace, the record consistently indicates normal stability upon testing, which goes against the assignment of a separate compensable rating for instability. The April 2019 VA examination report indicates that the Veteran reported a catching or “locking sensation” in her knee if she starts moving suddenly or at a faster pace. The examiner found a meniscal tear and frequent episodes of joint locking. The examiner noted that the Veteran’s meniscal tear was identified in service in 2003, and that the in-service surgery was performed on right anterior cruciate ligament laxity with right lateral meniscus tear. This indicates that the meniscus tear is part of the service-connected knee disability, rather than a new and separate disability. A January 2020 VA examination diagnosed residuals of right anterior cruciate ligament reconstruction, and specifically found that the Veteran does not have arthritis. The examiner noted a history of recurrent effusion in that the Veteran complained of intermittent swelling on excess physical activity. The record thus reflects that the Veteran has a tear to her meniscus or semilunar cartilage that is part of the service-connected right knee disability. The record also reflects that this meniscal tear results in locking and recurrent effusion. The assignment of separate ratings under a DC governing limitation of motion, such as DC 5260 or 5261, and a DC governing meniscal disability, such as DC 5258 and 5259, is not precluded as a matter of law. Lyles v. Shulkin, 29 Vet. App. 107 (2017). In this case, the record reflects that the Veteran has been assigned a 10 percent rating for painful limitation of flexion, and that the Veteran also suffers from locking and recurrent effusion. The Veteran thus meets the requirement for a separate rating under DC 5258 for frequent episodes of “locking,” pain, and effusion into the joint. Although both DC 5260 and DC 5258 contemplate pain, in this case, the separate rating is assigned for frequent episodes of “locking” and effusion into the knee joint that accompanies the pain. Therefore, the ratings are assigned for different symptoms, they do not constitute impermissible pyramiding. A separate rating of 20 percent and no higher for meniscal disability with frequent episodes of “locking” and effusion into the joint is thus appropriate. A rating higher than 20 percent is not available for a meniscal disability under the rating schedule. 6. Entitlement to a rating higher than 10 percent for a back disability The Veteran contends that she is entitled to a higher rating for her spondylolisthesis because of its impact on prolonged sitting, standing, and walking. The Veteran’s spondylolisthesis is currently rated under 38 C.F.R. § 4.71a, DC 5239. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. To the extent that a September 2015 examination did not describe limitation during flare ups with the required specificity, the Board notes that it is not possible to remedy this failing and obtain past flare ups range of motion readings with a new examination on remand. Therefore, the Board must make a decision based upon the evidence of record. In this case, the most limited range of motion findings in the record are a June 2019 VA examination finding flexion limited to 80 degrees, extension limited to 20 degrees, right and left lateral flexion limited to 30 degrees each, and right and left lateral rotation limited to 20 degrees each. This examination found no flare-ups. Aa June 2019 VA treatment note found that the Veteran’s trunk extension was limited by 50 percent. The Board will resolve doubt in the Veteran’s favor and find that in the June 2019 treatment note, the Veteran’s thoracolumbar spine extension was limited to 50 percent of normal, or 15 degrees. The record does not reflect that the Veteran’s flexion is limited to 60 degrees or less. Similarly, even taking the 15 degrees of extension found in the June 2019 treatment note into consideration, the combined range of motion of the thoracolumbar spine is more than the120 degrees or less that is required for a 20 percent rating. The Board has taken the Veteran’s lay statements of difficulty sitting, standing, or walking for prolonged periods of time due to back pain into consideration. This difficulty with pain is contemplated by the 10 percent rating assigned. DeLuca v. Brown, 8 Vet. App. 202 (1995). Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability, other than the radiculopathy that has been discussed above. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for spondylolisthesis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to a rating higher than 10 percent for asthma prior to May 5, 2015 is remanded. 2. Entitlement to a rating higher than 30 percent for asthma from May 5, 2015 is remanded. Evidence indicates that there may be outstanding relevant VA treatment records. As noted in the July 2020 JMR, the February 2015 VA examiner referenced a February 2015 pulmonary function test (PFT) that was available in VISTA imaging, but was not associated with the claims file. Similarly, a May 2015 VA treatment note references a May 18, 2015 consult with a private physician for asthma, but this consult was not associated with the claims file. Any VA treatment records are within VA’s constructive possession, and are considered potentially relevant to the issues on appeal. A remand is required to allow VA to obtain them. The record should also be updated to include VA treatment records compiled since May 8, 2020. 3. Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include depressive disorder, is remanded. The Board cannot make a fully-informed decision on the issue of service connection for an acquired psychiatric disorder other than PTSD, to include depressive disorder, because no VA examiner has opined whether the Veteran’s depressive disorder is related to service. Although the Veteran is service-connected for PTSD, the record reflects that she has also been diagnosed with depressive disorder during the period on appeal. 4. Entitlement to service connection for a disability other than PTSD manifested by sleep impairment, to include PND is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a disability other than PTSD manifested by sleep impairment, to include PND, because no VA examiner has opined as to the etiology of such a disability. The Board recognizes that the Veteran is service-connected for PTSD, and that PTSD often impairs one’s sleep. However, the Board is unable to determine, based on the record, if the Veteran’s sleep impairment is caused at least in part by another disability, such as PND, for which the Veteran has not been service-connected. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from May 2020 to the present. 2. Obtain the Veteran’s VA treatment records that are on the VISTA system, to include the PFT referenced in the February 2015 VA examination, and the May 18, 2015 consult from Dr. L. referenced in a May 31, 2015 VA treatment note. If the records from Dr. L. are not obtained as part of the VA treatment record, ask the Veteran to complete a VA Form 21-4142 for Dr. L. and make two requests for the authorized records from Dr. L. directly, unless it is clear after the first request that a second request would be futile. 3. After completion of the above, obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s depressive disorder, which was diagnosed in a February 2020 VA treatment note, is at least as likely as not (50 percent or greater probability) related to service, to include the incidents laid out in a March 2003 statement in support of claim for service connection for PTSD. The opinion offered must be supported by a complete rationale. If the examiner is unable to provide the requested opinion without a new examination, then a new examination 4. After completion of paragraphs 1 and 2, schedule the Veteran for a VA examination for her sleep impairment. The clinician must determine whether the Veteran has a disability other than PTSD resulting in sleep impairment, to include paroxysmal nocturnal dyspnea (PND). An impression of PND was noted in an April 2014 private treatment note. If the Veteran has a disability other than PTSD resulting in sleep impairment, to include PND, the clinician must provide an opinion as to whether it is at least as like as not (50 percent or greater probability) related to service, to include exposure to burn pits. If the Veteran’s sleep impairment cannot be attributed to any diagnosis, the examiner must consider whether the Veteran’s sleep disturbance is a sign or symptom of a medically unexplained chronic multi-symptom illness or an undiagnosed Gulf War illness. (Continued on the next page)   Each opinion offered must be supported by a complete rationale. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal. M.E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Budd, 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.