Citation Nr: 21008103 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 18-42 298 DATE: February 11, 2021 ORDER New and material evidence having been received, the previously denied claim of entitlement to service connection for a lumbar spine disability is reopened. Entitlement to service connection for degenerative disc disease of the lumbar spine disability is granted. REMANDED Entitlement to service connection for a sinus disability is remanded. Entitlement to service connection for sleep apnea, to include as secondary to a sinus disability, is remanded. Entitlement to service connection for an acquired psychiatric disorder, including, but not limited to, adjustment disorder with anxiety, claimed as posttraumatic stress disorder (PTSD), is remanded. FINDINGS OF FACT 1. The Veteran did not appeal a June 1992 Department of Veterans Affairs (VA) Regional Office (RO) decision that denied service connection for compression fracture, lumbar spine. 2. Additional evidence has been received since the June 1992 RO rating decision that relates to unestablished facts necessary to substantiate the previously denied claim of entitlement to service connection for a lumbar spine disability. 3. The Veteran’s degenerative disc disease of the lumbar spine had its onset during service. CONCLUSIONS OF LAW 1. The June 1992 RO decision that denied service connection for compression fracture, lumbar spine, is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.201, 20.302. 2. The evidence received after the June 1992 RO decision is new and material; the claim of entitlement to service connection for a lumbar spine disability is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for service connection for degenerative disc disease of the lumbar spine have been met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has multiple periods of active service, including from January 1988 to January 1992; October 2001 to October 2004; January 11, 2009, to May 7, 2009; June 8, 2009, to November 16, 2009; and May 13, 2014, to November 5, 2014, and has reserve service. In November 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ) of the VA Board of Veterans’ Appeals (Board) at a video-conference hearing; a hearing transcript has been associated with the claims file.   1. Whether new and material evidence has been received to reopen the previously denied claim of entitlement to service connection for compression fracture, lumbar spine. In general, VA rating decisions that are not timely appealed are final. See 38 U.S.C. § 7105; 38 C.F.R. § 20.302. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. New evidence is defined as evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156 (a). The Veteran’s claim of entitlement to service connection for compression fracture, lumbar spine, was last denied in a June 1992 RO rating decision, and the Veteran was notified of such in a June 1992 letter. No party filed a Notice of Disagreement (NOD) to the rating decision, there were no relevant service records that existed and had not been associated with the claims file when the RO first decided the claim, and there was no relevant new and material evidence, medical or lay, physically or constructively received by VA prior to the expiration of the appellate period. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156 (b)(c); 20.201. As such, the June 1992 RO rating decision is final. The Veteran’s claim was denied in June 1992 on the basis of his period of service from January 1988 to January 1992. Relevant evidence added to the record since the June 1992 decision includes additional statements of the Veteran as to the etiology of his disability and VA and private treatment records, as well as service treatment and personnel records related to subsequent periods of service from October 2001 to October 2004; January 11, 2009, to May 7, 2009; June 8, 2009, to November 16, 2009; and May 13, 2014, to November 5, 2014. In pertinent part, service treatment records for the period of service from October 2001 to October 2004 note in-service injuries to which the Veteran attributes his lumbar spine disability. Accordingly, the evidence is new, as it was not previously before decision makers, and the evidence is material, as it could serve as bases to substantiate the claim. The claim of entitlement to service connection for a lumbar spine disability has been reopened. 2. Entitlement to service connection for a lumbar spine disability. The Veteran asserts, during his November 2020 Board hearing, that while he had injured his lumbar spine prior to service at the age of 17, such had healed and he was deemed fit for duty and his lumbar spine disability was aggravated by in-service injuries. Service connection will generally be awarded when a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection on a direct basis, the evidence must show (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a link or nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 252 (1999). For the chronic diseases listed in 38 C.F.R. § 3.309(a), including arthritis, service connection may alternatively be established with evidence of chronicity of the disease during service or during a presumptive period following service separation, or by showing a continuity of symptoms after service when the condition noted during service, or a presumptive period, is not shown to be chronic at the time. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012). When chronicity or continuity is established, subsequent manifestations of the same chronic disease at any later date, no matter how remote in time from the period of service, will be service connected unless clearly attributable to causes unrelated to service ("intercurrent" causes). 38 C.F.R. § 3.303(b). The Veteran’s service treatment records include a November 1987 service entrance examination showing that the Veteran gave a history of a compression fracture of the lumbar spine prior to service. Clinical evaluation of his spine was normal. He was referred for an orthopedic evaluation of his spine. During a November 1987 orthopedic evaluation, the Veteran reported that two years prior he was riding on the back of a motorcycle which hit a car, that he essentially sat down hard, and had low back pain for two days with X-ray examination showing fracture. The Veteran reported that later X-ray examination revealed normal results. The orthopedist consultation report indicates that current physical examination was normal, including X-ray examination, and there were no signs of compressed fracture. Because a low back disorder, including a compression fracture, was not noted upon entry into service, the Veteran is presumed to be in sound condition. 38 U.S.C. § 1111. The Veteran’s service treatment records for his period of active duty from January 1988 to January 1992 are negative for any complaints or findings pertaining to his lumbar spine. On post-service VA examination in February 1992, the Veteran reported some low back pain during service but stated that presently his back was “ok.” Clinical evaluation of his spine was normal. X-ray examination of the lumbar spine, in February 1992, recorded in a VA examination, was also normal. He was diagnosed with fracture of the lumbar spine, motorcycle accident, by history only. On entrance examination in October 2001, for the Veteran’s period of service from October 2001 to October 2004, there were no complaint or findings pertaining to his lumbar spine. Again, because a low back disorder, including a compression fracture, was not noted upon entry into service, the Veteran is presumed to be in sound condition. 38 U.S.C. § 1111. The Veteran’s service treatment records include a July 2003 post-deployment health assessment in which he reported back pain. Service treatment records dated in November 2003 indicate that the Veteran reported back pain for three days after carrying a heavy object, X-ray examination revealed mild disc space narrowing at L5-S1, otherwise negative. In December 2003, the Veteran complained of continued low back pain and reported such occurred when he carried a fellow service member in a fireman’s carry position during physical training. The Veteran’s service treatment records dated after November 2003 include numerous complaints of low back pain and reports of the fireman’s carry incident, with numerous profiles. In March 2004, the Veteran reported that he was hit in the back by another player while playing sports and complained of upper and lower back pain. In May 2004, he reported low back pain after heavy lifting, referring to the fireman’s carry incident, with the acute onset of pain in the right lower spine, and reported that X-ray examination revealed degenerative disc disease; he was diagnosed with lumbar degenerative disc disease, retrolisthesis of L5 on S1, and chronic lumbar strain. In August 2004, he reported that he had been in the field and sleeping in vehicles, he complained of upper and lower back pain and denied trauma; he was diagnosed with muscle spasm and nonallopathic lesions, lumbar spine. In September 2004, the Veteran complained of upper and lower back pain after a two-mile ruck sack march. Post-service private treatment records dated in May 2012 indicate that the Veteran was involved in a motor vehicle accident in April 2012 and reported mid-back pain; magnetic resonance imaging (MRI) showed thoracic bulging and herniation; it does not appear that the Veteran reported lumbar spine symptoms or that his lumbar spine was examined. Service treatment records dated in January 2013 indicate that the Veteran reported back and knee pain since his April 2012 motor vehicle accident. The examiner noted that the Veteran met the strict deployment criteria, he was cleared, and he attended training without exacerbation of his injury and reported that the Veteran was a vital team player and had been assigned to duties that will not exacerbate his injury. In a September 2014 post-deployment health assessment, the Veteran reported that his back “bothered him a lot.” In December 2015, the Veteran’s private physician reported that the Veteran continued to have back pain from his in-service fireman’s carry; he was diagnosed with degenerative disc disease. In a February 2017 DBQ, the Veteran was diagnosed with degenerative arthritis of the spine. The examiner noted the Veteran’s report of back problems starting in 2003 or 2004 after lifting a heavy object, that X-ray examination revealed degenerative disc disease and he was on a profile, that he had chiropractic treatment, that he had an April 2012 motor vehicle accident, and that at entry into service he had a compression fracture of the lumbar spine at age 16. The examiner reported that she could not resolve the etiological issue without resorting to mere speculation on the basis that the Veteran had incurred multiple injuries to his back, some during active service and some during reserve service, and the extent to which every one of these injuries affects his current disability picture cannot be identified without resorting to mere speculation. Here, the initial diagnosis of a low back disorder, degenerative disc disease at L5-S1, occurred in November 2003, during the Veteran’s period of active duty from October 2001 to October 2004. Post-service treatment records show continued complaints concerning the Veteran’s lumbar spine and a current diagnosis of degenerative disc disease of the lumbar spine. As noted, in November 2015 the Veteran’s private physician reported that the Veteran continued to have back pain from his in-service fireman’s carry; he was diagnosed with degenerative disc disease. Resolving reasonable doubt in the Veteran’s favor, the Board finds that his current diagnosis of degenerative disc disease of the lumbar spine cannot reasonably be disassociated from his in-service diagnosis of degenerative disc disease of the lumbar spine in November 2003. As such, service connection is warranted for degenerative disc disease of the lumbar spine. See 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS FOR REMAND 1. Entitlement to service connection for a sinus disability and entitlement to service connection for sleep apnea, to include as secondary to a sinus disability, are remanded. In his March 2017 statement, the Veteran asserted that his in-service environmental exposure had not been disputed and that it is common knowledge that airborne particulates present at burn pit sites and during oil well fires can cause permanent respiratory damage. He asserted that given his lack of occupational or recreational exposures, his sinus disability is related to his in-service environmental exposure. In his March 2017 statement, he also asserted that it is common knowledge that obstructive sleep apnea is a common sequela of sinusitis and that given his lack of other risk factors for sleep apnea, his sleep apnea is related to his sinusitis. During his November 2020 Board hearing, the Veteran described his in-service environmental exposure, wearing full mission oriented protective posture (MPPO) gear, including oil fields, explosions from ammunition trucks and tanks, chemical paint in airplane hangars, burn pits, trash burning by locals, mustard gas used by the enemy, and having to travel past burning incinerators daily. He reported his presence near the Gulf of Aden, with air heavy from the water. He asserted that he tried to talk to a physician about his symptoms in 2014, a burning sensation in his nasal passages and wheezing, but was told to wait until got back from deployment. He reported that a physician, Dr. Reese, told him that his chemical exposure was at least as likely as not the source of his current issues and wrote a statement as to such in a DBQ. He asserted that his sleep apnea was related to service, in that he had in-service environmental exposure and snored badly during deployment in 2014 such that a fellow service member roommate had to leave; and also that such may be secondary to his sinus disability. In an April 2016 statement, one of the Veteran’s fellow service members asserted that he was a roommate with the Veteran during service in Djibouti and witnessed him snoring. The Veteran’s service treatment records dated in April 1990 indicate that he complained of a runny nose for two weeks; he was diagnosed with rhinorrhea second to probable upper respiratory infection. In a May 1991 Report of Medical History, he reported a history of ear, nose, and throat problems. In a May 1991 Southwest Asia Demobilization Medical Evaluation, the Veteran also reported a cough or sinus infection and trouble sleeping. In a May 1992 VA examination, the Veteran reported heavy smoke inhalation in Iraq; physical examination was negative, he was diagnosed with exposure to heavy smoke inhalation. In a July 2003 Post Deployment Health Assessment, the Veteran reported service in Southwest Asia, Iraq, and Kuwait, and reported that he was an armor crewman, wearing MOPP and gas masks due to alerts and not exercises on two occasions, and entering or closely inspecting destroyed military vehicles. He reported that he was exposed to smoke from oil fire sometimes, smoke from burning trash/feces often, vehicle or truck exhaust often, tent heater smoke sometimes, JP-8 and other fuels often, and sand/dust often. He reported that he experienced, in pertinent part, a runny nose and fever. In an October 2009 Master Workplace Exposure Data Summary, it appears that the Veteran was exposed to hazardous and other waste, with JP-8 and benzene noted. A July 2011 Clinical Occupational Health Examination Requirements appears to indicate exposure to methyl ethyl ketone, strontium chromate, JP-8, benzene (all below action level), lubricants, hazardous and other wastes. A November 2011 Clinical Occupational Health Examination Requirements appears to indicate exposure to toluene, methyl ethyl ketone, isopropanol, petroleum distillates, benzene, and polymethyl dioxane. In a September 2014 Post Deployment Health Assessment, the Veteran reported service in Djibouti. He reported shortness of breath bothering him a little and worrisome exposure to burning trash and dust. In a June 2015 DBQ, signed by an unidentified private physician, the Veteran was diagnosed with allergic rhinitis and sinusitis, without comment as to etiology thereof. In a July 2015 DBQ, signed by Wahba Wahba, M.D. the Veteran was diagnosed with sleep apnea, obstructive, central, and mixed components of both, without comment as to etiology thereof. It was noted that the Veteran had a sleep study in January 2015. In private treatment records dated in September 2015, the physician reported that the Veteran presented for a discussion of his hazardous environmental exposure during deployments and requested a letter in support of his claim. The Veteran was diagnosed with chemical exposure and the physician reported, in his opinion, per the Veteran’s recollection of his military and environmental exposure, his sleep apnea and allergic rhinitis and chronic sinusitis are at least as likely as not the source of his current issues. In a February 2017 DBQ conducted by VA, the Veteran was diagnosed with chronic sinusitis and allergic rhinitis, both onset many years prior. The Veteran reported a long history of sinus congestion, the onset of which he did not recall, but associated such with 2003 in Iraq where he breathed in a lot of smoke and dust, and was exposed to burn pits, oil fires, and other Southwest Asia environmental hazards. It does not appear that the examiner offered an etiological opinion as to the Veteran’s sinus disability. In a February 2017 DBQ, the Veteran was diagnosed with sleep apnea by sleep study, 2015. The examiner reported that the etiological issue cannot be resolved without resorting to mere speculation, as the Veteran has severe obstructive sleep apnea and such is almost always associated with severe obesity causing obstruction of the airways at night during sleep and the Veteran is not obese; his severe obstructive sleep apnea is unexplainable. To date, there are no adequate etiological opinions as to the Veteran’s sinus disability and sleep apnea. The Veteran’s private physician, in his September 2015 statement, did not offer any rationale for his conclusion which appears to attribute a sinus disability and sleep apnea to in-service environmental exposure. There is no VA etiological opinion as to the Veteran’s sinus disability and the VA examiner, regarding his sleep apnea, did not appear to consider any in-service snoring or respiratory symptoms or in-service environmental exposure. On remand, the RO should afford the Veteran VA examinations of his sinus disability and sleep apnea and obtain adequate etiological opinions. Further, a copy of the Veteran’s sleep study conducted in January 2015 should be obtained. The RO, on remand, should also provide the Veteran adequate notice as to his claim of entitlement to service connection for sleep apnea on a secondary basis related to a sinus disability. 2. Entitlement to service connection for an acquired psychiatric disorder, including, but not limited to, adjustment disorder with anxiety, claimed as PTSD, is remanded. In an April 2016 PTSD statement, the Veteran reported that in July 2003, one of his fellow service members was killed by an improvised explosive device (IED) and that in March or April 2003, his Captain was killed and he had to help recover pieces of the body. In his March 2017 statement, the Veteran asserted that while he had been diagnosed on VA examination with adjustment disorder, he had cardinal symptoms of PTSD, and that VA had verified his in-service combat stressors. During his November 2020 Board hearing, the Veteran reported that he had a great deal of fear of hostile activities in Iraq, crossing the border into Iraq and seeing “some pretty horrific stuff.” He reported that he lost a fellow service member to a IED and had to pick up the body parts of a Captain; asserting that VA had already verified multiple combat-related incidents. He noted that a fellow service member died in the loader’s hatch of a tank in an IED incident and the Veteran would have been in the hatch if the fellow service member been there. The Veteran also reported private treatment during which he had been diagnosed with PTSD. His service separation document, his DD-214, for his period of active service dated from October 2001 to October 2004 indicates service in Kuwait/Iraq from November 22, 2020, to August 11, 2003, an imminent danger pay area. In a May 1991 Southwest Asia Demobilization Medical Evaluation, the Veteran reported nightmares or trouble sleeping and recurring thoughts about his experience during Desert Shield/Storm. The examiner noted terminal insomnia and interrupted sleep or dreams about war experiences, consider PTSD. In a July 2003 Post Deployment Health Assessment, the Veteran reported service in Southwest Asia, Iraq, and Kuwait, and reported that he saw wounded/killed/dead coalition and that he felt that he was in great danger of being killed. A July 2016 response from the Defense Personnel Records Information Retrieval System (DPRIS) indicates that the fellow service member named by the Veteran in his PTSD stressor statement was indeed killed in an IED in July 2003. During Vet Center treatment in July 2015 and August 2015, the Veteran reported similar in-service stressors as he had previously, noting small arms fire. His testing results did not necessarily indicate PTSD, however, the treatment provider noted that the Veteran reported experiencing some symptoms of PTSD; he was diagnosed with adjustment disorder. An August 2015 Vet Center notation indicates that the Veteran appeared to have symptoms of PTSD. In a February 2017 DBQ, the Veteran was diagnosed with anxiety disorder with anxiety. He reported multiple combat experiences, the IEDs, being involved in body recovery Iraq in 2004, and witnessing the “highway of death” between Kuwait and Basra. The Veteran reported in-service counseling after the death of his fellow service member. The examiner noted that there was no mental health symptoms or treatment in the Veteran’s service or VA treatment records and asserted that it was not possible to formally relate the Veteran’s anxiety disorder with service, that there was no documented history of in-service mental health treatment or interventions and it appeared much more likely than not that the Veteran’s stress management capabilities have been limited by his intrinsic personality organization. In a September 2019 letter, the Veteran’s private physician reported that the Veteran had been diagnosed with long-standing PTSD. During VA treatment in January 2020, the Veteran reported several instances of military trauma including one of his troops dying by IED and seeing “a lot of death and destruction.” He was diagnosed with adjustment disorder with mixed emotions, trauma-related stress disorder, rule-out PTSD second to military career. A January 2020 VA mental health treatment record includes impressions of adjustment disorder with mixed emotions; trauma related stress disorder, rule out PTSD; and insomnia. The February 2017 VA etiological opinion is inadequate as it appears the examiner based their opinion on the lack of documented in-service and post-service mental health symptoms and intervention. On remand, the RO should afford the Veteran an VA examination to determine the precise nature of any acquired psychiatric disorder, including PTSD, and the etiology thereof. As to each of the claims remanded herein, save for the VA documents related to VA examinations and limited VA treatment records submitted by the Veteran himself, it appears that the most recent VA treatment records are dated in June 2010, while they appear to have been printed or associated with the claims file in June 2018. On remand, the RO should obtain and associate with the claims file the Veteran’s complete and updated VA treatment records. The matters are REMANDED for the following action: 1. Provide the Veteran adequate notice as to his claim of entitlement to service connection for sleep apnea on a secondary basis to any sinus disability. 2. Obtain and associate with the claims file the Veteran’s complete and updated VA treatment records, specifically, those dated from June 2010 to the present. 3. Obtain and associate with the claims file the Veteran’s complete treatment records from Ryan Rees, M.D., dated from January 2005 forward. 4. Obtain and associate with the claims file the Veteran’s complete treatment records from Wahba Wahba, M.D., dated from January 2015 forward, including, but not limited to, a copy of the January 2015 sleep study. 5. Schedule the Veteran for a VA examination for his sinus disability. The examiner must review the claims file. All indicated tests and studies must be completed. A complete rationale must be provided for any opinions rendered. Is the Veteran’s sinus disability at least as likely as not (at least 50 percent probability) related to service, specifically, his: (1) in-service environmental exposure to burn pit, oil well fires, wearing full MPPO gear, explosions from ammunition trucks and tanks, chemicals in paint in airplane hangars, trash burning by locals, mustard gas used by the enemy, entering or closely inspecting destroyed military vehicles, heavy smoke inhalation, air heavy from the water of the Gulf of Aden, vehicle or truck exhaust, tent heater smoke, toluene, JP-8 and other fuels, sand/dust, benzene, methyl ethyl ketone, strontium chromate, isopropanol, lubricants, petroleum distillates, polymethyl dioxane, hazardous and other wastes, and having to travel past burning incinerators daily; (2) in-service symptoms of a burning sensation in his nasal passages and wheezing during and after deployment, his reported snoring during deployment, his April 1990 runny nose diagnosed as rhinorrhea second to probable upper respiratory infection, his reported history of ear, nose, and throat problems (including a cough and sinus infection) in May 1991, his July 2003 runny nose and fever, and/or his September 2014 shortness of breath; and (3) the Veteran’s lay assertion as to a lack of occupational or recreational exposures to which any sinus disability may be attributed? In providing the requested opinion, consider the Veteran’s description of his in-service environmental exposure and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported in-service environmental exposure and symptoms in service and thereafter represented the onset of his current sinus disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? 6. Schedule the Veteran for a VA examination for his sleep apnea. The examiner must review the claims file. All indicated tests and studies must be completed. A complete rationale must be provided for any opinions rendered. (a) Is the Veteran’s sleep apnea at least as likely as not (at least 50 percent probability) related to service, specifically, his: (1) in-service environmental exposure to burn pit, oil well fires, wearing full MPPO gear, explosions from ammunition trucks and tanks, chemicals in paint in airplane hangars, trash burning by locals, mustard gas used by the enemy, entering or closely inspecting destroyed military vehicles, heavy smoke inhalation, air heavy from the water of the Gulf of Aden, vehicle or truck exhaust, tent heater smoke, toluene, JP-8 and other fuels, sand/dust, benzene, methyl ethyl ketone, strontium chromate, isopropanol, lubricants, petroleum distillates, polymethyl dioxane, hazardous and other wastes, and having to travel past burning incinerators daily; (2) in-service symptoms of a burning sensation in his nasal passages and wheezing during and after deployment, his reported snoring during deployment, his April 1990 runny nose diagnosed as rhinorrhea second to probable upper respiratory infection, reported history of ear, nose, and throat problems (including trouble sleeping) in May 1991, his July 2003 runny nose and fever, and his September 2014 shortness of breath; and (3) the Veteran’s lay assertion as to a lack of occupational or recreational exposures to which any sleep apnea may be attributed ? In providing the requested opinion, consider the Veteran’s description of his in-service environmental exposure and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported in-service environmental exposure and symptoms in service and thereafter represented the onset of his current sleep apnea, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? (b) Is the Veteran’s sleep apnea at least as likely as not (at least 50 percent probability) proximately due to any sinus disability, specifically considering the Veteran’s lay statement that obstructive sleep apnea is a common sequela of sinusitis and that given his lack of other risk factors for sleep apnea? (c) Is the Veteran’s sleep apnea at least as likely as not (at least 50 percent probability) aggravated, i.e., worsened beyond its natural progression, by any sinus disability, specifically considering the Veteran’s lay statement that obstructive sleep apnea is a common sequela of sinusitis and that given his lack of other risk factors for sleep apnea? 7. Schedule the Veteran for a VA examination for his acquired psychiatric disorder, including, but not limited to adjustment disorder with anxiety, claimed as PTSD. The examiner must review the claims file. All indicated tests and studies must be completed. A complete rationale must be provided for any opinions rendered. (a) The examiner must determine if a diagnosis of PTSD is appropriate, and if not, the examiner must discuss: (1) the reasons why a diagnosis of PTSD is not appropriate; and (2) the propriety of any prior diagnosis of PTSD of record. (b) For any PTSD diagnosed, are the Veteran’s in-service stressors, specifically, his witnessing one of his fellow service members killed by an IED and having to help recover body pieces of his Captain when he was killed, feeling that he was in great danger of being killed, experiencing small arms fire, and witnessing the “highway of death” between Kuwait and Basra, adequate to support a diagnosis of PTSD based on a fear of hostile military or terrorist activity during service, meaning that the Veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, and the Veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror, and whether his symptoms are related to the in-service stressor(s)? (c) For any acquired psychiatric disorder, including, but not limited to, adjustment disorder with anxiety, is such at least as likely as not (at least 50 percent probability) related to his in-service stressors, specifically, his witnessing one of his fellow service members killed by an IED and having to help recover body pieces of his Captain when he was killed, feeling that he was in great danger of being killed, experiencing small arms fire, and witnessing the “highway of death” between Kuwait and Basra? • In providing these opinions, the examiner should consider the May 1991 Southwest Asia Demobilization Medical Evaluation, wherein the Veteran reported nightmares or trouble sleeping and recurring thoughts about his experience during Desert Shield/Storm, with the examiner noting terminal insomnia and interrupted sleep or dreams about war experiences, consider PTSD. In providing the requested opinion, the examiner should consider the Veteran’s description of his in-service stressors and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported in-service symptoms and symptoms in service and thereafter represented the onset of his current acquired psychiatric disorder, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Department of Veterans Affairs 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.