Citation Nr: 21007323 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 17-67 642 DATE: February 9, 2021 ORDER An evaluation in excess of 40 percent for fibromyositis of the lumbar muscles is denied. REMANDED Entitlement to a separate evaluation for left lower extremity radiculopathy as related to service-connected fibromyositis of the lumbar muscles is remanded. Entitlement to service connection for peripheral neuropathy and mild degenerative joint disease (DJD) of the knees, to include as secondary to service-connected fibromyositis of the lumbar muscles is remanded. Entitlement to service connection for peripheral neuropathy and mild degenerative joint disease (DJD) of the hands, to include as secondary to service-connected fibromyositis of the lumbar muscles is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as secondary to service-connected anxiety disorder NOS and fibromyositis of the lumbar muscles is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDING OF FACT The Veteran’s fibromyositis of the lumbar muscles is manifested by impairment with painful limited motion most nearly approximating forward flexion to 30 degrees or less without ankylosis or incapacitating episodes requiring bed rest prescribed by a physician. CONCLUSION OF LAW The criteria for a rating in excess of 40 percent for fibromyositis of the lumbar muscles are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4,10, 4.71a, Diagnostic Code 5021-5237. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1960 to March 1962. This matter is before the Board of Veterans’ Appeals (Board) on appeal from November 2014, May 2015, and December 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In a June 2018 decision, the Board issued a decision denying a rating in excess of 40 percent for fibromyositis of the lumbar muscles, denying the claim to reopen a claim for service connection for peripheral neuropathy and mild DJD of the hands, and reopened the claim for service connection for peripheral neuropathy and mild DJD of the knees. The issues of service connection for peripheral neuropathy and mild DJD of the knees, bilateral hearing loss, tinnitus, GERD, sleep apnea, and TDIU were remanded for further development. The Veteran appealed the Board’s denials to the United States Court of Appeals for Veterans Claims (Court). In a June 2019 order, the Court vacated the June 2018 decision as it pertained to the denial of a rating in excess of 40 percent for fibromyositis of the lumbar muscles, and the denial of a claim to reopen a claim for service connection for peripheral neuropathy and mild DJD of the hands and remanded the matters to the Board for further proceedings consistent with a Joint Motion for Partial Remand (JMR). These issues were then remanded by the Board in November 2019 for further development. During the pendency of the remand, the Veteran was granted service connection for tinnitus in a June 2020 decision review officer decision. As this is a full grant of the benefit sought, that issue is no longer before the Board. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran’s fibromyositis of the lumbar muscles is currently rated as 40 percent disabling since January 4, 2001 under 38 C.F.R. § 4.71a, Diagnostic Code 5201-5237. VA received a claim for increased compensation in 2014. Hyphenated Diagnostic Codes are used when a rating under one diagnostic code requires the use of an additional one to identify the basis for the rating assigned; the additional diagnostic code is shown after the hyphen. 38 C.F.R. § 4.27. Diagnostic Code 5021 provides that myositis is rated on limitation of motion of the affected parts, as degenerative arthritis (except for gout). Under the General Rating Formula for Diseases and Injuries of the Spine (which includes Diagnostic Code 5237), 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. Unfavorable ankylosis is defined as “a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching.” Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is “always” considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). 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). At a November 2014 VA examination, the Veteran reported daily flare-ups which were described as severe, lasting hours, precipitated with prolonged walking/sitting/standing. Range of motion testing showed forward flexion of 0 to 20 degrees with objective evidence of pain. Pain was noted and caused functional loss. There was no evidence of pain with weight bearing. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function of range of motion. Pain significantly limited functional ability with repeated use over time and would demonstrate forward flexion of 0 to 15 degrees. Pain significantly limited functional ability with flare-ups, but an opinion concerning additional range of motion loss during flare-ups was no feasible because the Veteran did not experience a flare-up during the examination. The Veteran had muscle spasm and tenderness resulting in abnormal gait or abnormal spine contour. There was decreased sensation in the foot/toes. Straight leg raising was positive in the left. The Veteran had mild radiculopathy in the left lower extremity. There was no ankylosis. The Veteran had intervertebral disc syndrome (IVDS) but did not require bed rest prescribed by a physician and treatment by a physician in the past 12 months. The Board notes that in April 2015, the Veteran submitted authorization for VA to obtain private treatment records in Centro de Terapia Fisica in Hatillo and Camuy. However, in December 2019, the Veteran’s representative notified VA that the records were destroyed because the file was more than five years old. The representative indicated that VA should proceed with the evidence of record. The Court has held that, where records are unavailable, “VA has no duty to seek to obtain that which does not exist.” Counts v. Brown, 6 Vet. App. 473, 477 (1994); Porter v. Brown, 5 Vet. App. 233, 237 (1993). Therefore, VA has no further duty to assist in obtaining these records. VA treatment records in the file, including from June 2019, indicate that the Veteran had decreased range of motion secondary to chronic pain, but muscle tone was adequate and there were no deformities. At a January 2020 VA examination, the Veteran stated that he had continued pain and limitations that require back flexion movements. He needed help from his wife for dressing with regard to lower extremities. The Veteran did not report flare-ups. The reported functional loss/impairment was limited back flexion movements. Range of motion testing showed forward flexion of 0 to 20 degrees with objective evidence of pain. Pain was noted on forward flexion and caused functional loss, limitation in reaching ground level objects from a standing position. There was no evidence of pain with weight bearing. There was evidence of localized tenderness or pain on palpation. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function of range of motion. Pain significantly limited functional ability with repeated use over time and would demonstrate forward flexion from 0 to 15 degrees. The muscle spasm resulting in abnormal gait or abnormal spinal contour. Straight leg testing was normal and there was no radicular pain or signs or symptoms due to radiculopathy. There was also no ankylosis and no IVDS. The functional impact of the Veteran’s condition was that he was limited to functional activities with no back twisting, bending, heavy lifting, carrying, pushing, or pulling, and no prolonged standing or ambulation. There was pain with passive range of motion, but it did not result in functional loss. There was no pain with weight bearing or non-weight bearing. The Board finds that the preponderance of the evidence is against a rating in excess of 40 percent for fibromyositis of the lumbar muscles. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he has daily pain and problems such as standing, ambulation, bending, twisting, and lifting would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. There is no diagnosis or evidence of unfavorable ankylosis of the thoracolumbar spine or the entire spine in the record, to include the 2014 and 2020 VA examination reports. VA treatment records indicate no deformities. The provisions of 38 C.F.R. § 4.40 and § 4.45 are not for consideration where, as here, the Veteran is in receipt of the highest rating based on limitation of motion and a higher rating requires ankylosis. Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997); DeLuca v. Brown, 8 Vet. App. 202, 205-08 (1995). Therefore, the Board cannot conclude that the Veteran’s disability most nearly approximates ankylosis when he clearly retained some motion of the thoracolumbar spine. The Board finds that the competent evidence of record establishes that the Veteran’s thoracolumbar spine was not ankylosed, and a rating in excess of 40 percent is not warranted based on limitation of motion and functional factors. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. In fact, the November 2014 and January 2020 VA examination reports specifically found that the Veteran had not required bed rest prescribed by a physician and treatment by a physician in the past 12 months. Additionally, the January 2020 VA examiner found that the Veteran did not have IVDS. The Board finds this competent evidence tends to weigh against the use of the Formula for IVDS. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 40 percent for fibromyositis of the lumbar muscles. 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. The Board notes that the November 2014 VA examination shows that the Veteran had mild left lower extremity radiculopathy. As discussed below, the Board is remanding the issue of whether the Veteran is entitled to separate ratings for neurological symptoms. REASONS FOR REMAND Entitlement a separate evaluation for Left Lower Extremity Radiculopathy As indicated above, separate ratings for any related neurological complaints are part of the evaluation of an increased rating for a lumbar claim. The November 2014 VA examination noted mild left lower extremity radiculopathy; however, the January 2020 VA examination reports notes that the Veteran did not have radiculopathy. The Veteran had been previously diagnosed with clinical lumbar radiculopathy at left side in a September 2011 VA examination, but it was determined that it was not associated with the Veteran’s service-connected fibromyositis of the lumbar muscles. VA treatment records from February 2018 note lumbar radiculopathy symptoms and decreased sensation in the left leg and positive straight leg test. Based on the foregoing conflicting evidence, the Board finds that the record is unclear as to the nature and severity of any lower extremity radiculopathy throughout the period on appeal. As such, a remand is warranted so the Veteran can be scheduled for a VA examination to determine whether the Veteran has lower extremity radiculopathy associated with the Veteran’s service-connected fibromyositis of the lumbar muscles. Peripheral Neuropathy and DJD of the Knees and Hands The Veteran is seeking service connection for peripheral neuropathy and DJD of the knees and hands, which he claims was due to service and his service-connected fibromyositis of the lumbar muscles. In the June 2018 remand, the Board directed that the Veteran be afforded a new VA examination which identified all knee conditions present from May 2014 to the present, and opine as to whether it is at least as likely as not that any diagnosed knee condition is related to the Veteran’s service and proximately due to or aggravated by his service-connected fibromyositis of the lumbar muscles. The Veteran underwent a VA examination in April 2019. The examiner indicated that the Veteran has bilateral knee DJD, but it was not at least as likely as not that any diagnosed knee condition is related to the Veteran’s service because there were no knee issues in service to suggest a connection. The examiner also indicated that it was not at least as likely as not that any diagnosed knee condition was proximately due to or aggravated by his service-connected fibromyositis of the lumbar muscles. There was no medical evidence to suggest a lumbar strain or fibromyositis causes peripheral neuropathy. The Veteran had spinal stenosis, DJD which is most likely the cause of his peripheral neuropathy. His knee DJD had no relation to his service-connected fibromyositis of the lumbar muscles, as the Veteran had age-related arthritis in his knees. However, the examiner did not explain what “medical evidence” was needed to suggest that a lumbar strain or fibromyositis causes peripheral neuropathy. Furthermore, insofar as the examiner concluded that the Veteran’s knee DJD was likely age-related, the examiner did not provide any supporting rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008) (“[A] medical opinion... must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions.”). The examiner also did not provide a rationale as to aggravation. Given these deficiencies, the Board finds that an addendum opinion is necessary. Regarding the claim for service connection for peripheral neuropathy and DJD of the hands, the Board, in the November 2019 remand, directed that the Veteran be provided a VA examination which addressed whether it was at least as likely as not that peripheral neuropathy and DJD of the hands was related to service and caused or aggravated by the Veteran’s service-connected fibromyositis of the lumbar muscles. The Veteran underwent a VA examination in January 2020. The examiner indicated that it was less likely than not that peripheral neuropathy and DJD were related to service, because service treatment records were silent for the condition, and bilateral hand DJD is considered part of the normal aging process in patients older than 40 years old. Osteoarthritis and carpal tunnel syndrome were not related to service because they were incurred/diagnosed several years after last day of service. Regarding secondary service connection, the examiner stated that hand osteoarthritis and carpal tunnel syndrome were not related pathophysiologically or anatomically to the service-connected lumbar condition. There was no evidence in medical literature to support any etiology that links aggravation of osteoarthritis and carpal tunnel syndrome to the service-connected lumbar condition. The examiner did not provide any supporting rationale for the findings that hand osteoarthritis and carpal tunnel syndrome were not related pathophysiologically or anatomically to the service-connected lumbar condition. Id. Also, the found no aggravation based solely on the lack of medical literature, but did not consider the Veteran’s treatment records, which includes a September 1992 VA treatment record which notes a history of chronic lower back pain with evidence of radiculopathy in the upper extremity. An addendum opinion is also needed in this for these issues. GERD The Veteran contends that service connection is warranted for GERD. In a February 2015 statement, the Veteran indicated that he was seeking service connection for GERD resulting from his service-connected conditions and due to the medications he was prescribed for his service-connected conditions. The Board’s June 2018 remand directed that a new examination and opinion be provided as the May 2015 VA examiner did not address the discrepancy in his opinion and did not provide additional information needed for aggravation claims, including whether base-line severity of GERD could be determined. The Board directed that the examiner opine as to whether it is at least as likely as not that GERD was proximately due to or aggravated by the Veteran’s service-connected conditions, to include medications prescribed for these conditions. The Veteran underwent a VA examination in April 2019. The examiner opined that the Veteran’s GERD was less likely than not due to or aggravated by the Veteran’s anxiety disorder NOS and fibromyositis of the lumbar muscles. The examiner indicated that GERD was not due to anxiety disorder, and that there is no medical documentation to support that. The Veteran’s symptom of occasional sour taste in his mouth with certain foods was unrelated to medications and mainly related to food triggers. The examiner stated that they had no idea what the May 2015 VA examiner was referring to, and that the Veteran has occasional heartburn that was well-controlled on Ranitidine. The Veteran is 70 years old and has never had a UGI series or any concerning signs or symptoms to warrant further investigation. GERD was not related to military service or other service-connected conditions. The Veteran’s GERD was also not aggravated beyond its natural progression by his other medications as there was nothing to indicate that the Veteran has pill induced esophagitis. However, in providing this opinion, the examiner did not discuss why GERD was proximately due to the Veteran’s other service-connected disorders (fibromyositis lumbar muscles, tinnitus, and erectile dysfunction). Also, while the examiner discussed whether GERD was not aggravated beyond its natural progression by the Veteran’s medications, there was no discussion as to whether GERD was aggravated by the Veteran’s service-connected conditions. Remand is needed for an addendum medical opinion addressing these discrepancies. Sleep Apnea The Veteran is also seeking service connection for sleep apnea. In his August 2015 notice of disagreement, the Veteran indicated that he began receiving treatment following service and his condition has worsened. The Board’s June 2018 remand directed that the Veteran be provided a VA examination to determine the etiology of his sleep apnea. The Veteran underwent a VA examination in April 2019. The examiner indicated that the Veteran’s sleep apnea was less likely than not due to enlarged tonsils noted in service. He was not diagnosed until 2005 and there was nothing to suggest that he had symptoms of sleep apnea within a reasonable time from separation. Enlarged tonsils did not automatically lead to sleep apnea. The risk of sleep apnea increased with age and weight. In providing this opinion, the examiner did not explain conclusion that the Veteran did not have symptoms of sleep apnea within a “reasonable time from separation.” In addition, VA treatment records show that the Veteran had symptoms of sleep disordered breathing in 2003 and was actually diagnosed with sleep apnea in 2004 following a VA sleep study. Remand is needed for an addendum opinion with a complete rationale. Bilateral Hearing Loss The Veteran underwent a VA examination in November 2014, where the examiner stated that the Veteran had normal hearing during active duty and that there was no evidence of complaints of hearing loss for more than 40 years after service. Therefore, it was highly probable that bilateral hearing loss was due to presbycusis or hearing loss expected as a normal aging process. Therefore, hearing loss was less likely than not related to service. However, in rendering this opinion, the examiner did not consider the Veteran’s noise exposure in service as an Armour Crewman, and that he received a marksman and sharpshooter badge. Also, the Veteran subsequently underwent a VA examination in April 2019 (no opinion was provided), where it was indicated that the Veteran did not have noise exposure following service. The April 2019 VA examiner also stated that the Veteran’s service-connected tinnitus is at least as likely as not a symptom associated with his clinical hearing loss, as tinnitus is known to be a symptom associated with hearing loss. There is no opinion as to whether the Veteran’s bilateral hearing loss is related to or aggravated by his service-connected tinnitus. As such, remand for an addendum opinion is needed. TDIU Regarding the issue of entitlement to TDIU, it is dependent on the outcome of the service connection claims being remanded. Therefore, the Board also remands the claim for TDIU as inextricably intertwined with the service connection claims. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (stating two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered); Tyrues v. Shinseki, 23 Vet. App. 166, 178 (2009). All Issues While on remand, updated VA treatment records should be obtained. These matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records for the period from February 2020 to the present. 2. After completing the development in item 1, schedule the Veteran with an appropriate examination to determine whether the Veteran has left lower extremity radiculopathy throughout the course of the appeal period. The electronic claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail. The examiner must state whether there is left lower extremity radiculopathy associated with the Veteran’s service-connected fibromyositis of the lumbar muscles. If so, the examiner is requested to assess the current severity of any diagnosed left radicular symptoms. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. After completing the development in item 1, return the claims file to the VA examiners who provided the April 2019 VA medical opinion regarding peripheral neuropathy and DJD of the knees and the January 2020 medical opinion regarding peripheral neuropathy and DJD of the hands for addendum opinions. The examiner must review the entire claims file, including a copy of this Remand. If the VA examiners who provided the April 2019 and January 2020 opinions are not available, then forward the Veteran’s claims file to another appropriate specialist to obtain the below requested medical opinions. Following a review of the Veteran’s claims file, the examiner must answer the following questions: a) Peripheral neuropathy and DJD of the knees Is it at least as likely as not (a 50 percent or greater probability) that any peripheral neuropathy and/or degenerative joint disease of the knees was caused by an in-service injury, event, or disease? Is it at least as likely as not (a 50 percent or greater probability) that any peripheral neuropathy and/or degenerative joint disease of the knees, was caused by the Veteran’s service-connected fibromyositis of the lumbar muscles? Is it at least as likely as not (a 50 percent or greater probability) that any peripheral neuropathy and/or degenerative joint disease of the knees, was aggravated (that is, any increase in severity beyond the natural progression of the condition) by the Veteran’s service-connected fibromyositis of the lumbar muscles? b) Peripheral neuropathy and DJD of the hands Is it at least as likely as not (a 50 percent or greater probability) that any peripheral neuropathy and/or degenerative joint disease of the hands was caused by an in-service injury, event, or disease? Is it at least as likely as not (a 50 percent or greater probability) that any peripheral neuropathy and/or degenerative joint disease of the hands, was caused by the Veteran’s service-connected fibromyositis of the lumbar muscles? Is it at least as likely as not (a 50 percent or greater probability) that any peripheral neuropathy and/or degenerative joint disease of the hands, was aggravated (that is, any increase in severity beyond the natural progression of the condition) by the Veteran’s service-connected fibromyositis of the lumbar muscles? A complete rationale for all opinions must be provided for all the questions posed. The examiner is reminded that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 4. After completing the development in item 1, return the claims file to the VA examiner who provided the April 2019 VA medical opinion regarding the Veteran’s GERD for an addendum opinion. The examiner must review the entire claims file, including a copy of this Remand. If the VA examiner who provided the April 2019 opinion is not available, then forward the Veteran’s claims file to another appropriately qualified examiner to obtain the below requested medical opinions. Following a review of the Veteran’s claims file, the examiner must answer the following: a) Is it at least as likely as not (a 50 percent or greater probability) that GERD was caused by the Veteran’s service-connected conditions (anxiety disorder NOS, fibromyositis lumbar muscles, tinnitus, and erectile dysfunction), to include but not limited to, medications prescribed for these conditions? b) Is it at least as likely as not (a 50 percent or greater probability) that GERD was aggravated (that is, any increase in severity beyond the natural progression of the condition) by the Veteran’s service-connected conditions anxiety disorder NOS, fibromyositis lumbar muscles, tinnitus, and erectile dysfunction), to include but not limited to, medications prescribed for these conditions? A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 5. After completing the development in item 1, return the claims file to the VA examiner who provided the April 2019 VA medical opinion regarding the Veteran’s sleep apnea for an addendum opinion. The examiner must review the entire claims file, including a copy of this Remand. If the VA examiner who provided the April 2019 opinion is not available, then forward the Veteran’s claims file to another appropriately qualified examiner to obtain the below requested medical opinions. Following a review of the Veteran’s claims file, the examiner must answer the following: Is it at least as likely as not (a probability of 50 percent or greater) that sleep apnea is etiologically related to the Veteran’s service, to include hypertrophied tonsils noted at the February 1962 separation examination? In providing this opinion, the examiner should explain the previous statement that the Veteran did not have symptoms of sleep apnea within a “reasonable time from separation.” In addition, the examiner should note that VA treatment records show that the Veteran had symptoms of sleep disordered breathing in 2003 and the Veteran was diagnosed with sleep apnea in 2004 following a VA sleep study. A complete rationale for all opinions must be provided for all the questions posed. The examiner is reminded that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 6. After completing the development in item 1, return the claims file to the VA examiner who provided the April 2019 VA medical opinion regarding the Veteran’s bilateral hearing loss for a medical opinion. The examiner must review the entire claims file, including a copy of this Remand.   If the VA examiner who provided the April 2019 opinion is not available, then forward the Veteran’s claims file to another appropriately qualified examiner to obtain the below requested medical opinions. Following a review of the Veteran’s claims file, the examiner must answer the following: a) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s bilateral hearing loss was caused by his exposure to acoustic trauma during service, including as an Armor Crewman, an occupational specialty with a high probability of exposure to loud noises. The examiner must note that, under applicable law, the absence of in-service evidence of a hearing loss disability is not always fatal to a service connection claim. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Evidence of a current hearing disability and a medically sound basis for attributing that disability to service may serve as a basis for a grant of service connection for hearing loss where there is credible evidence of acoustic trauma due to significant noise exposure in service. Hensley v. Brown, 5 Vet. App. 155, 159 (1993). b) Is it at least as likely as not (a 50 percent or greater probability) that bilateral hearing loss was proximately due to the Veteran’s service-connected tinnitus? c) Is it at least as likely as not (a 50 percent or greater probability) that bilateral hearing loss was aggravated (that is, any increase in severity beyond the natural progression of the condition) by the Veteran’s service-connected tinnitus? A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Bonnie Yoon, 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.