Citation Nr: 21007488 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 18-20 704 DATE: February 9, 2021 ORDER Entitlement to a compensable rating for a coronary artery bypass graft surgical scar is DENIED. Entitlement to a rating of 60 percent, but no greater, for coronary artery disease status post triple heart bypass, myocardial infarction and stent is GRANTED. Entitlement to service connection for an unspecified depressive disorder with cannabis abuse is DENIED. REMANDED Entitlement to service connection for sleep apnea is REMANDED. Entitlement to service connection for a posttraumatic stress disorder (PTSD) disability is REMANDED.   FINDINGS OF FACT 1. During the claim period, the record does not reflect that the Veteran’s 15.24 cm X .25 cm sternal scar was painful and/or unstable. 2. During the appellate period, the Veteran was evaluated with a workload of greater than 3 METs but not greater than 5 METs, which resulted in fatigue and dizziness. The Veteran did not demonstrate arteriosclerotic heart disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. 3. The weight of the evidence is against a finding that the Veteran’s currently diagnosed unspecified depressive disorder with cannabis abuse either began during, or was otherwise caused by, his military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to a compensable rating for a coronary artery bypass graft surgical scar have not been met. 38 U.S.C. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code (DC) 7805. 2. The criteria for rating of 60 percent, but no greater, for coronary artery disease status post triple heart bypass, myocardial infarction and stent have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.21, 4.104, DC 7005 (2020). 3. The criteria for entitlement to service connection for unspecified depressive disorder with cannabis abuse have not been satisfied. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In April 2018, the Veteran submitted a VA Form 9. Therein, the Veteran requested a Board videoconference hearing on the issues listed on the title page. In December 2019, the Veteran was notified that a videoconference hearing was scheduled in March 2020. After review, the Board notes that the hearing was cancelled. The Board also notes that the representative of record relayed that the Veteran was withdrawing his appeal. In December 2020, correspondence was sent to the Veteran and his representative. Therein, VA relayed that, “we need to verify whether it was your intent to withdraw the appeals, and whether that intent remains the same. A request for withdrawal of an appeal must be in writing and signed.” The Veteran was notified that the Board would proceed with appellate review if the required withdrawal was not received in 30 days. The claim file does not contain the requisite withdrawal; consequently, the Board will proceed with appellate review. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran’s lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev’d on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and the duration of the symptoms that accompany his service-connected sternal scar and CAD. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). As noted above, the Veteran’s entire history is reviewed when assigning a disability evaluation. 38 C.F.R. § 4.1. However, where service connection has already 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). In determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Board must consider whether there have been times when his disabilities on appeal have been more severe than at others, and rate them accordingly. 1. Entitlement to a compensable rating for a coronary artery bypass graft surgical scar is denied. In September 2017, the AOJ issued a rating decision. At that time, the AOJ granted service connection for a coronary artery bypass graft surgical scar; the AOJ assigned a non-compensable disability rating. In November 2017, the Veteran submitted a notice of disagreement (NOD). Therein, the Veteran contested the non-compensable rating assigned for the coronary artery bypass graft surgical scar. The Veteran’s surgical chest scar is rated under Diagnostic Code 7805, scars other. 38 C.F.R. § 4.118. In general, the rating criteria for scars are provided under DCs 7800, 7801, 7802 and 7804. In addition, Diagnostic Code 7805 provides that any disabling effect(s) not considered in a rating provided under DCs 7800-7804 should be evaluated under an appropriate Diagnostic Code. Id. Under Diagnostic Code 7801, scars not of the head, face or neck that are deep and nonlinear and cover an area or areas of at least six square inches (39 square cm) but less than 12 square inches (77 square cm) warrant a 10 percent rating. Higher ratings are warranted for scars covering larger areas. Id. Under Diagnostic Code 7802, scars not of the head, face or neck that are superficial and nonlinear and cover an area or areas of 144 square inches (929 square cm) or greater warrant a 10 percent rating. Id. Under DC 7804, the presence of one or two scars that are unstable or painful warrants a 10 percent disability rating. Three or four scars that are unstable or painful warrant a 20 percent rating. The presence of five or more scars that are unstable or painful warrant a 30 percent rating. Note (1) explains that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Under Note (2), if one or more scars are both unstable and painful, 10 percent is to be added to the rating that is based on the total number of unstable or painful scars. Id. In August 2017, the Veteran underwent a VA examination that addressed the severity of heart conditions. At that time, the Veteran reported that, after the triple bypass surgery (1999), he had incision pain during the first year. The Veteran reported intermittent itching to the chest scar. The VA examiner noted a sternal scar that measured 15.24 cm X .25 cm. The VA examiner noted that the Veteran’s sternal scar was not painful and/or unstable. During the claim period, the Veteran’s government and private treatment records have been associated with the claims file multiple times. After review, the Board finds that the treatment records do not reflect that the Veteran’s sternal scar was painful and/or unstable at any point during the claim period. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s increased rating claim for a sternal surgical scar. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for a compensable rating for sternal surgical scar must be denied, because the preponderance of the evidence weighs against his claim. 2. Entitlement to a rating of 60 percent, but no greater, for coronary artery disease (CAD) status post triple heart bypass, myocardial infarction and stent is granted. In September 2017, the AOJ issued a rating decision. At that time, the AOJ granted service connection for CAD; the AOJ assigned a 10 percent rating for the service-connected disability. In November 2017, the Veteran submitted a notice of disagreement (NOD). Therein, the Veteran contested the 10 percent rating assigned for the CAD disability. Under Diagnostic Code (DC) 7005, arteriosclerotic heart disease (coronary artery disease) resulting in workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; when continuous medication is required, is rated 10 percent disabling. The next higher rating of 30 percent is awarded for arteriosclerotic heart disease resulting in workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray. Arteriosclerotic heart disease resulting in more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent, is rated 60 percent disabling. Arteriosclerotic heart disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent, is rated 100 percent disabling. 38 C.F.R. § 4.104, DC 7005. For rating diseases of the heart, one MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for rating, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note 2. In addition, the Rating Schedule provides that, when rating under Diagnostic Codes 7000 through 7007, 7011, and 7015 through 7020, the following provisions apply: (1) Whether or not cardiac hypertrophy or dilatation (documented by electrocardiogram, echocardiogram, or X-ray) is present and whether or not there is a need for continuous medication must be ascertained in all cases. (2) Even if the requirement for a 10 percent rating (based on the need for continuous medication) or a 30 percent rating (based on the presence of cardiac hypertrophy or dilatation) is met, METs testing is required in all cases except when there is a medical contraindication, when the left ventricular ejection fraction has been measured and is 50 percent or less, when chronic congestive heart failure is present or there has been more than one episode of congestive heart failure within the past year, and when a 100 percent evaluation can be assigned on another basis. (3) If left ventricular ejection fraction (LVEF) testing is not of record, evaluation should be based on alternative criteria unless the examiner states that the LVEF test is needed in a particular case because the available medical information does not sufficiently reflect the severity of the Veteran’s cardiovascular disability. 38 C.F.R. § 4.100. In March 2016, an echocardiogram report was generated at the New Mexico Heart Institute. The report revealed a left ventricular ejection fraction of 56 percent. In April 2017, the Veteran’s treatment notations from Presbyterian were associated with the claims file. Therein, a provider noted an ejection fraction of approximately 50 percent. In August 2017, the Veteran underwent a VA examination that addressed the severity of heart conditions. The VA examiner noted diagnoses for myocardial infarction, CAD, cardiomyopathy, hypertensive heart disease, coronary artery bypass graft, and cardiac stent. The VA examiner noted that the Veteran had not endured congestive heart failure. The VA examiner noted the echocardiogram revealed a left ventricular ejection fraction of 66 percent. The VA examiner noted that exercise stress testing is not required as part of the Veteran’s current treatment plan and METs testing is not without significant risk. During an interview-based METs test, the Veteran reported fatigue and dizziness. The VA examiner reported that the Veteran could demonstrate a workload of greater than 3 METs but not greater than 5 METs. During the appellate period, the Veteran was evaluated with a workload of greater than 3 METs but not greater than 5 METs, which resulted in fatigue and dizziness. Consequently, a 60 percent rating is warranted under 38 C.F.R. § 4.104, DC 7005. During the claim period, the Veteran’s government and private treatment records have been associated with the claims file multiple times. After review, the Board finds that the Veteran did not demonstrate arteriosclerotic heart disease resulting in chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. The Board notes that the Veteran’s private treatment records report a history of ischemic congestive cardiomyopathy and chronic diastolic heart failure with an unknown etiology. However, the Board finds that the Veteran’s public and private treatment records do not support that he suffered from arteriosclerotic heart disease resulting in chronic congestive heart failure. Consequently a 100 percent rating is not warranted under 38 C.F.R. § 4.104, DC 7005. Ultimately, the preponderance of the evidence favors the Veteran’s claim for a rating of 60 percent, but no greater, for the service-connected CAD disability. Accordingly, this service-connection claim must be granted. The Board notes that the Veteran and his representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted while in the active military, naval, or air service. 38 U.S.C. § 1110. 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). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In each case where service connection for any disability is sought, due consideration shall be given to the places, types, and circumstances of the Veteran’s service as shown by the Veteran’s service record, the official history of each organization in which the Veteran served, the Veteran’s medical records, and all pertinent medical and lay evidence. 38 U.S.C. § 1154 (a). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Barr v. Nicholson, 21 Vet. App. 303 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board must give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 3. Entitlement to service connection for an unspecified depressive disorder with cannabis abuse is denied. In April 2017, the Veteran submitted a VA Form 21-526EZ. Thereby, the Veteran initiated a claim for service connection for an unspecified depressive disorder. Again, direct service connection generally requires (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson, 12 Vet. App. at 253. In April 2017, the Veteran’s treatment notations from Presbyterian were associated with the claims file. Therein, a provider reported negative suicidal ideation, anxiety, depression, or other psychiatric disorders. In June 2017, the Veteran’s service treatment records (STRs) were associated with the claims file. After review, the Board notes that records do not contain a notation to support that the Veteran was treated for, or diagnosed with, depression during service in the United States Navy. During his separation examination, the Veteran did not report depression and/or nervous trouble. The military examiner did not report a psychiatric condition after the clinical evaluation. In July 2017, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured PTSD. The VA examiner noted diagnoses for unspecified depressive and cannabis use disorders. The VA examiner opined that, “(t)he diagnoses of unspecified depressive disorder and cannabis use disorder are less likely the result of an in-service stressor related event.” The VA examiner supplied the following rationale: “(t)he veteran reports difficulty adjusting to civilian life due to what he perceived to be mistreatment by others. Based on the available information, the veteran appears to have a history of adjustment difficulties prior to, during, and after his period of service. This fact seems to be supported, at least in part, by a history of maladaptive behavior, misconduct, and alcohol/substance use that started in adolescence and continued into adulthood.” The Board notes that the Veteran has diagnoses for unspecified depressive and cannibis-use disorders. Consequently, the first requisite element for direct service connection has been substantiated. See Hickson, 12 Vet. App. at 253. However, the Board notes that the Veteran’s STRs are devoid of a notation that supports in-service depression. Moreover, the July 2017 VA examiner opined that the Veteran’s current depression was not etiologically linked to the Veteran’s service in the United States Navy. Consequently, the second and third requisite elements have not been substantiated for the Veteran’s claim for service connection for an unspecified depressive disorder with cannabis abuse. See id. Ultimately, the Board finds that the preponderance of the evidence stands counter to the Veteran’s claim for service connection for an unspecified depressive disorder with cannabis abuse. Since the preponderance of the evidence is against this claim, the provisions of 38 U.S.C. § 5107(b), regarding reasonable doubt, are not applicable. The Veteran’s claim for service connection for an unspecified depressive disorder with cannabis abuse must be denied, because the preponderance of the evidence weighs against his claim. REASONS FOR REMAND The Veteran served honorably in the United States Navy form December 1964 to April 1969. The certificate of release from active duty (DD214) reflects that the Veteran received the Vietnam Service Medal and a Vietnam Campaign Medal. Upon review of the record, the Board concludes that further evidentiary development is necessary. Although the Board sincerely regrets this delay and is appreciative of the Veteran’s service to his country, a remand is necessary to ensure VA provides the Veteran with appropriate assistance in developing his claim prior to final adjudication. 4. Entitlement to service connection for sleep apnea is remanded. In April 2017, the Veteran submitted a VA Form 21-526EZ. Thereby, the Veteran initiated a claim for service connection for a sleep apnea disability. In February 2015, a report was generated at Davita Medical Group. Therein, the provider assessed obstructive sleep apnea diagnosis. The Veteran relayed that he woke up choking, and he sometimes choked as he fell asleep. The Veteran reported that he had snored badly for many years. The Veteran reported sleeping alone for 20 years; consequently, no one ever reported apnea spells. After a sleep study, a provider assessed severe central sleep apnea and moderate obstructive sleep apnea. To date, there is no medical opinion associated with the claims file that addresses a link, if any, between the Veteran’s military service and the currently diagnosed sleep apnea. Therefore, the Board finds that a remand to the AOJ for a VA examination is warranted. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (recognizing that 38 C.F.R. § 3.159 (c) (4) presents a low threshold for the requirement of a VA examination).   5. Entitlement to service connection for a posttraumatic stress disorder (PTSD) disability is remanded. In April 2017, the Veteran submitted a VA Form 21-526EZ. Thereby, the Veteran initiated a claim for service connection for PTSD. Service connection for PTSD has unique evidentiary requirements. It generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (i.e., DSM-IV or DSM-5); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f); see also Cohen v. Brown, 10 Vet. App. 128 (1997). As for the second PTSD requirement, an in-service stressor, the evidence necessary to establish the occurrence of any in-service stressor varies depending upon the circumstances of the case. VA has provided for specific types of cases where lay evidence alone may be sufficient to describe the stressor and further corroborating evidence will not be required. Corroborating evidence is not required in cases when the evidence establishes the Veteran engaged in combat with the enemy and the claimed stressor is related to that combat. 38 C.F.R. § 3.304. In this situation, the Veteran’s lay testimony or statement is accepted as conclusive evidence of the stressor’s occurrence and no further development or corroborative evidence is required providing that such evidence is found to be consistent with the circumstances, conditions, or hardships of service and there is no clear and convincing evidence to the contrary. See 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304. In April 2017, the Veteran submitted two VA Form 21-0781s. In the first, the Veteran relayed that, “confined for hours day & night during heavy bombardment.” In the second, the Veteran relayed that, “during General Quarters confined to an area about 4 x 5. Next to 5” canons which were constantly being fired. 8hr shift (alone).” In April 2017, a Mental Health Note was generated at the Raymond G. Murphy VA Medical Clinic (VAMC). Therein, a provider assessed a provisional diagnosis for PTSD. In July 2017, the Veteran underwent a VA examination that addressed the nature and etiology of any currently endured PTSD. The VA examiner reported that the Veteran did not maintain a PTSD diagnosis under the DSM-V criteria. The Veteran relayed that his stressor event was as follows: “rude or cruel treatment by civilians who called him names etc when they learned that he served in Vietnam.” The VA examiner reported that the Veteran did not satisfy all of the DSM-V criteria for a PTSD diagnosis. The VA examiner supplied the following rationale: “(t)he veteran's reported stressors do not meet criteria for a diagnosis of PTSD, as they did not involve fear of hostile military or terrorist activity. The veteran reports difficulty adjusting to civilian life due to what he perceived to be mistreatment by others. Based on the available information, the veteran appears to have a history of adjustment difficulties prior to, during, and after his period of service. This fact seems to be supported, at least in part, by a history of maladaptive behavior, misconduct, and alcohol/substance use that started in adolescence and continued into adulthood.” The Board notes that the July 2017 VA examiner did not address the Veteran’s April 2017 report(s) of in-service stressors. As the VA examiner’s negative opinion was primarily based on the fact that there was no in-service stressor, the Board finds that it was based on an inaccurate factual premise, which renders the opinion inadequate. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative). Accordingly, on remand, an addendum opinion regarding the nature and etiology of any PTSD currently endured by the Veteran should be obtained. Barr v. Nicholson, 21 Vet. App. 303, 31 (2007). Consequently, the matters are REMANDED to the AOJ for the following action: 1. The Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of any currently endured sleep apnea. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any currently endured sleep apnea had its clinical onset during military service, or is otherwise related to the Veteran’s active duty service? (b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that any sleep apnea currently endured by the Veteran was either (i) caused by or (ii) aggravated by one of the Veteran’s service-connected disabilities? Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as any incremental increase in disability attributable to the service-connected disability, i.e., any additional impairment of earning capacity that is above the degree of disability existing before the increase, regardless of its permanence. See Ward v. Wilkie, No. 16-2157, 2019 U.S. App. Vet. Claims LEXIS 994 (June 14, 2019). If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his sleep apnea. 2. If available, the July 2017 VA examiner should supply an addendum opinion that addresses the nature and etiology of any PTSD currently endured by the Veteran. The examiner must be provided access to the Veteran’s electronic claims files, including the Veterans Benefit Management System (VBMS) and Legacy Content Manager (LCM) databases. The examiner must specify in the examination report that the claims files has been reviewed. The examiner should identify any current PTSD endured by the Veteran and provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such PTSD was occurred in or is otherwise etiologically related to the Veteran’s military service. The examiner must address the medical records indicating treatment for symptoms of PTSD. The examiner must address the Veteran’s April 2017 statements about in-service stressors. The examiner should determine whether the diagnostic criteria to support a diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should indicate whether the PTSD is related to the Veteran’s fear of hostile military or terrorist activity during his period of active service from December 1964 to April 1969. A rationale for any opinion reached should be provided. If the VA examiner concludes that an opinion cannot be offered without engaging in speculation then he/she should indicate this and explain the reason why an opinion would be speculative. 4. After completing any other development that may be warranted, the AOJ should readjudicate the claims on appeal. If the benefits sought are not granted, the Veteran and his representative must be given a supplemental statement of the case (SSOC) and a reasonable opportunity to respond before the record is returned to the Board. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board RLBJ, 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.