Citation Nr: 21008766 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 19-27 132 DATE: February 18, 2021 ORDER New and material evidence has been received, the claim for service connection for degenerative joint disease, lumbar spine is reopened. New and material evidence has been received, the claim for service connection for hypertension is reopened. Service connection for hernia, right side is denied. Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. REMANDED Service connection for degenerative joint disease, lumbar spine is remanded. Service connection for bilateral knee condition is remanded. Service connection for bilateral hip condition is remanded. Service connection for a skin condition is remanded. Service connection for hypertension is remanded. Service connection for bilateral eye condition is remanded. Service connection for erectile dysfunction is remanded. Service connection for sleep apnea is remanded. FINDING OF FACT 1. A June 2012 rating decision denied service connection for lumbar spine degenerative joint disease and hypertension; the Veteran did not appeal these issues, and new and material evidence was not received within one year of notice of issuance. 2. The evidence received since the June 2012 rating decision is new and related to an unestablished fact necessary to substantiate the claim and raises a reasonable possibility of substantiating the claims. 3. The preponderance of the evidence is against finding that the Veteran’s right-side hernia began during active service or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that the Veteran has an acquired psychiatric disorder that began during active service or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW 1. New and material evidence has been received to reopen the claim of entitlement to service connection for degenerative joint disease, lumbar spine. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for hypertension. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.102, 3.156(a). 3. The criteria for service connection for hernia, right side have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for an acquired psychiatric disorder, to include PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304 (f). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1965 to June 1967. This matter comes before the Board of Veterans’ Appeals (Board) from August 2017 and March 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In June 2020, the Veteran testified before the undersigned Veterans Law Judge at a virtual hearing. A transcript is of record. Although new evidence was received following the August 2019 statement of the case, the evidence was duplicative and/or irrelevant to the issues being decided herein. Accordingly, no waiver or supplemental statement of the case is necessary. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.800 (c). NEW AND MATERIAL EVIDENCE Generally, a previously denied claim in an unappealed Board decision or an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104 (b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to VA; material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156 (a). 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. 38 C.F.R. § 3.156 (a); see Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510,513 (1992). Entitlement to service connection for lumbar spine degenerative joint disease and hypertension was previously denied in a June 2012 rating decision due to a lack of evidence that either condition occurred in or was caused by service. The Veteran did not perfect an appeal of the decision nor was any new and material evidence received within one year of notification of the decision. Therefore, the June 2012 rating decision became final as to these issues. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In June 2017, the Veteran sought to reopen his claims. The evidence of record since the June 2012 rating decision includes, in pertinent part, July 2017 correspondence from Dr. Marks-Snelling, the Veteran’s private physician. In the opinion from Dr. Marks-Snelling opined that it is as least as likely that the degenerative joint disease of the lumbar spine is secondary to the Veteran’s military occupational specialty duties. This evidence is new (as it was not previously considered by the RO) and also material because it relates to establishing a medical nexus for lumbar spine degenerative joint disease (a previously unestablished fact) and it raises a possibility of substantiating the claim. Additionally, while no new and material evidence was presented in support of reopening the claim of service connection for hypertension, the Board takes judicial notice of the November 2018, the Veterans and Agent Orange: Update 11 (2018), publication from the National Academy of Sciences Institute of Medicine (NAS) which upgraded hypertension to the “sufficient” category from “limited or suggestive,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide agent exposure. See Veterans and Agent Orange: Update 11 (2018). On this basis, the Board will reopen and consider entitlement to hypertension on the merits, as the NAS study pertains to causal nexus (a previously unestablished fact) and provides a basis for finding there is a reasonable possibility of substantiating the claim. Accordingly, new and material evidence has been received, and the claims are reopened. SERVICE CONNECTION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Additionally, the law provides a presumption of service connection for certain diseases associated with exposure to herbicide agents and that become manifest within a specified time period, even if there is no record of evidence of such disease during the period of service. Veterans who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, or in or near the Korean demilitarized zone (DMZ) between April 1, 1968, and August 31, 1971, are presumed to have been exposed to herbicide agents. See 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6). For those veterans who have been exposed to herbicide agents, certain enumerated diseases are presumptively related to such exposure. 38 U.S.C. § 1116 (a)(2); 38 C.F.R. § 3.309 (e). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the certain diseases shall be service-connected, if the requirements of 38 C.F.R. § 3.307 (a) are met, even if there is no record of such disease during service. If a veteran was engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304 (d). This statute does not eliminate the need for evidence of a nexus; it merely reduces, for veterans who have engaged in combat with the enemy, the burden of presenting evidence of incurrence or aggravation of an injury or disease in service. Collette v. Brown, 82 F.3d 389, 392 (Fed. Cir. 1996) (“Section 1154(b) does not create a statutory presumption that a combat veteran’s alleged disease or injury is service-connected”). The provisions of 38 U.S.C. § 1154 (b) do not establish a presumption of service connection for a combat veteran, but ease or lessen the combat veteran’s burden of proof for demonstrating the occurrence of some in-service incident to which the current disability may relate. Clyburn v. West, 12 Vet. App. 296, 303 (1999); Wade v. West, 11 Vet. App. 302, 304-05 (1998). The Veteran’s military personnel records confirm he served in Vietnam, but do not reflect combat service. The Veteran also was not awarded any medals indicative of combat. Based on the foregoing, the Veteran is not considered a ‘combat Veteran.’ Service connection for hernia, right side is denied. The Veteran contends he has a right-side hernia related to his military occupational specialty (artillery specialist) and/or due to herbicide agent exposure in service. For the reasons that follow, service connection is not warranted. The Veteran service treatment records and June 1967 Report of Medical Examination are silent for complaints, treatment, or a diagnosis of a hernia condition. Post-service records include a November 2012 radiology report showing an umbilical hernia with small bowel protruding through without obstruction. The evidence does not include a medical opinion or other competent medical evidence suggesting a causal nexus between a current hernia condition and the Veteran’s military service. Service connection for a hernia may not be presumed. While the Veteran’s military personnel records reflect service in Vietnam, this condition is not one that is enumerated in 38 C.F.R. § 3.309(e) as having a presumptive relationship to herbicide agent exposure. A hernia is also not a chronic disease that warrants consideration of presumptive service connection under 38 C.F.R. § 3.307(a)(3), 3.309(a). The Veteran is not competent to provide an opinion regarding causal nexus because determining the etiology of his hernia condition is medically complex, and he has not been shown to possess the necessary skills and training to render a complex medical opinion or diagnosis. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). His unsupported lay contention is of little probative weight. VA has no duty to assist the Veteran in substantiating this claim by providing a medical examination or opinion because there is no indication of a nexus to herbicide agent exposure during active service. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for a hernia condition is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 5. Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. The Veteran seeks service connection for an acquired psychiatric disorder, to include PTSD. The Veteran contends his PTSD is related to his service in Vietnam. For the reasons that follow, the Board finds entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is not warranted. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304 (f). If the evidence establishes a diagnosis of PTSD during service and the claimed stressor is related to that service, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. If a stressor claimed by a veteran is related to the veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. “Fear of hostile military or terrorist activity” means that a 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, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304 (f). If a veteran did not engage in combat with the enemy, or the claimed stressors are not related to combat, and the stressor is not related to “fear of hostile military or terrorist activity,” then the veteran’s testimony alone is not sufficient to establish the occurrence of the claimed stressors and his testimony must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997); Moreau v. Brown, 9 Vet. App. 389 (1996); Dizoglio v. Brown, 9 Vet. App. 163 (1996). Furthermore, service records must support, and not contradict, the claimant’s testimony regarding non-combat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). The question of whether a veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 1991 (1991). Hence, whether a stressor was of sufficient gravity to cause or support a diagnosis of PTSD is a question of fact for medical professionals, and whether the evidence establishes the occurrence of stressors is a question of fact for adjudicators. Thus, the threshold question is whether the Veteran has a current diagnosis of PTSD, or another acquired psychiatric disorder, during the appeal period. Brammer v. Derwinski, 3 Vet. App. 223 (1992); 38 C.F.R. §§ 3.304 (f), 3.317. The Veteran’s service treatment records are silent for any complaints of, treatment for, or diagnoses related to an acquired psychiatric disorder. The Veteran’s July 1965 enlistment and June 1967 separation reports of medical examination reflect normal clinical psychiatric evaluations. The Veteran also denied a history of frequent trouble sleeping, frequent or terrifying nightmares, depression or excessive worry, and nervous trouble of any sort on his July 1965 enlistment and July 1967 separation reports of medical history. VA treatment records after service include evidence of psychiatric diagnoses years after discharge from service. A December 2009 VA treatment record notes anxiety disorder not otherwise specified (NOS) as an active problem. Other records since that time show diagnoses of PTSD, depressive disorder NOS, and a reported history of depression and/or anxiety. The Veteran underwent a VA PTSD examination in April 2012. The examiner indicated that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD; however, he does meet the diagnostic criteria for anxiety disorder, NOS. During the examination, the Veteran reported not socializing with friends often and tending to spend his time alone since returning from the military. Regarding stressors, the Veteran reported being under mortar fire on several occasions during his tour in Vietnam and being in constant fear of being shot during his 24-hour patrols. A July 2017 correspondence from the Veteran’s private physician, Dr. Marks-Snelling, D.O., MPH reflects a diagnosis of PTSD and severe depression and anxiety secondary to Vietnam mental trauma and chronic ongoing symptoms. The Veteran reported constant mortar attacks very close to him and so many bullet holes in his tent that he could see stars at night. He also reported that his friend was killed in Vietnam, which left him fearing for his life daily. The physician opined that that it is at least as likely as not that his chronic depression/anxiety and PTSD are secondary to Vietnam experiences. In support, the examiner noted that mental health literature confirms that combat exposure to the above during war time can lead to permanent negative mental impairments like chronic anxiety, depression, and PTSD. The Veteran underwent another VA PTSD examination in August 2017. The examiner indicated that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD and noted a diagnosis of other specified depressive disorder with anxious distress in remission. During the examination, the Veteran denied seeking mental health treatment during his military service. He denied mental health hospitalizations since discharge from the military and no current mental health treatment. The examiner noted his treatment records reflect he was diagnosed with PTSD in June 2014 after being changed from a mood disorder. The examiner indicated the majority of his prior assessments had ruled out a diagnosis of PTSD. Regarding stressors, the Veteran reported seeing ‘some VC that had chopped their head off and dragged behind a truck.’ The examiner opined that the Veteran does not meet criteria for PTSD or any other identifiable mental disorder. In support, the examiner noted that the results of the examination considered all available evidence with particular attention to treatment records and the various diagnoses assigned therein. The examiner noted evidence of a history of reported anxiety, depression, sleep difficulty, sleep apnea, and stressors that support criterion A for PTSD. However, the majority of treatment records and assessments from multiple providers considered and did not assign a diagnosis of PTSD; however, one did after initially assigning a mood disorder. Finally, the examiner noted that the examination did not identify sufficient criterion B-E symptoms to support a PTSD diagnosis or a separate psychiatric diagnosis. The Veteran underwent another VA PTSD examination in February 2018. The examiner indicated that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD but diagnosed major depressive disorder, recurrent, moderate with anxious distress. During the examination, the Veteran reported his family started complaining about his behavior soon after he returned from Vietnam. He indicated treatment with medication. Regarding stressors, the Veteran reported seeing an ammunition dump blow up and heard incoming mortars and people screaming incoming and running for cover. He also reported that he feared having to send up balloons at two a.m. every day that had a light attached and made him a target. He further indicated that their tent got shot up often and he came to fear the nighttime. Finally, he reported seeing dead soldiers dragged through the streets. The examiner opined that the Veteran’s condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner indicated that there is no evidence that it is related to his military service as there are no reports of mental health issues during service and no consistent reports of ongoing mental health problems since military service. The examiner further noted that, based on his examination, the Veteran meets criteria for a major depressive disorder with anxious distress diagnosis. However, his symptoms appear related to stress associated with his wife's recent stroke and him feeling overwhelmed regarding whether he will be able to take care of her at home post discharge. During the examination, the Veteran reported that his wife was the person who provided him with support and guidance, and the thought of becoming her caregiver is quite stressful to him. Thus, although the Veteran reported significant stressors that he experienced in Vietnam, he does not report the constellation of symptoms and behaviors necessary to meet criteria for PTSD at this time. There does not appear to be any connection between his current depression symptoms and his military experience. The Veteran underwent another VA examination in June 2019. The examiner indicated that the Veteran’s symptoms do not meet the criteria for PTSD; however, the examiner diagnosed major depressive disorder. Regarding stressors, the Veteran reported witnessing a sergeant’s head being hit by a helicopter and dying and being in Vietnam and fearing for life. The examiner opined that the Veteran’s condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support, the examiner noted there is no evidence that it is related to the Veteran’s military service. The examiner noted there is no report of mental health issues during the Veteran’s service time and no consistent report of ongoing mental health problems since military service. After a review of the evidentiary record, the Board finds that the preponderance of the evidence weighs against finding entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is warranted. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. Nieves-Rodriguez, 22 Vet. App. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Regarding the Veteran’s asserted diagnosis of PTSD, the Board recognizes that the RO conceded the Veteran experienced a stressful event in service or fear of hostile military or terrorist activity. However, the Board finds that the competent and most persuasive evidence of record demonstrates the Veteran has not had a diagnosis of PTSD at any time during the pendency of the claim or recent to the filing of the claim. While some of the Veteran’s post-service treatment records and a July 2017 correspondence from the Veteran’s private physician (Dr. Marks-Snelling) reflect a history of PTSD, the diagnoses appear to be based on the Veteran’s self-reported medical history alone. Moreover, in comparing the diagnoses of PTSD in the VA medical records and from Dr. Marks-Snelling to the VA examiners’ opinions, the Board finds the latter more probative. In this respect, the Board observes that the VA examiners’ opinions were based on evaluations of the Veteran and also review of his claims file, which provided details of his service history and a comprehensive view of his clinical history and complaints. The assessments by the VA examiners are more detailed and comprehensive in nature, and supported with rationale that explains the rationale underpinning the assessments. The Board also affords more probative weight to the VA examiners than the opinion from Dr. Marks-Snelling because of the clinicians’ areas of expertise. Dr. Marks-Snelling is not a psychiatrist or psychologist. Rather, he is doctor of osteopathic medicine. The VA examiners who provided diagnoses and opinions were all licensed psychiatrists or psychologists. Their areas of expertise are in the field of mental health, as opposed to Dr. Marks-Snelling. The VA clinicians also reviewed the claims file, which provided them an accurate factual premise with respect to the Veteran’s assertion of combat-related events and his relevant clinical history. Consequently, the Board gives more probative weight to the April 2012, August 2017, February 2018, and June 2019 VA examiners’ findings- that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD and that his non-PTSD psychiatric diagnoses are not related to military service events. Regarding the non-PTSD psychiatric diagnoses, competent medical evidence of a nexus between them and military service has not been established. In reaching this conclusion, the Board finds the VA examinations and opinions to be the most probative evidence of record. While the Veteran is competent to report psychiatric symptoms since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of his currently diagnosed disability. Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014); Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009); see also Waters v. Shinseki, 601 F.3d 1274, 1277 1278 (Fed. Cir. 2010). The issue is medically complex, as it requires knowledge and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Therefore, it is outside the competence of the Veteran because the record does not show that he has the medical training or credentials to make such a determination. Id.; see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Moreover, even if he were competent to make such a determination, the Board finds the Veteran’s reports of such continuity of symptoms to be not credible as they are inconsistent with his contemporaneous treatment records, which indicate the Veteran denied a history of such associated symptoms at separation from service. In conclusion, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. Accordingly, service connection for an acquired psychiatric disorder, to include PTSD, is not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, at 55-57. REASONS FOR REMAND 1. Service connection for degenerative joint disease, lumbar spine is remanded. 2. Service connection for bilateral knee condition is remanded. 3. Service connection for bilateral hip condition is remanded. 4. Service connection for a skin condition is denied. The Veteran contends his lumbar spine and bilateral hip and knee conditions onset during service and may be related to in-service herbicide agent exposure. The Veteran also contends his skin condition onset during service and may be related to in-service herbicide agent exposure. In July 2017 correspondence the Veteran’s private physician, Dr. Marks-Snelling, opined that the Veteran has current diagnoses of degenerative joint disease of the bilateral hips and lumbar spine. Dr. Marks-Snelling opined that these conditions are due to the Veteran’s occupational duties as an artillery specialist and his experience as a ‘Vietnam combat soldier,’ which included wearing combat gear weighing over 75 pounds. In the same correspondence, Dr. Marks-Snelling also noted the Veteran has a current diagnosis of onychomycosis of the bilateral toenail. Dr. Marks-Snelling opined that it is at least as likely as not that the Veteran’s chronic fungal disease of the toenails is due to swampy conditions in Vietnam. Although it does not appear that Dr. Marks-Snelling reviewed the claims file and notwithstanding the fact that the Veteran is not considered a combat Veteran within the meaning of 38 U.S.C. § 1154(b), his military occupational specialty was artillery specialist and he did have service in Vietnam. These opinions, while not entirely probative, are sufficient to compel VA to obtain a VA examination or opinion in these matters in accordance with McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Service connection for hypertension is remanded. The contends his hypertension is due to herbicide agent exposure in service or, alternatively, secondary to his service-connected coronary artery disease. The Veteran’s VA treatment records reflect a diagnosis of hypertension. See, e.g., May 2019 VA treatment record. His military personnel records reflect that he served in Vietnam. Therefore, he is presumed to have been exposed to herbicide agents. 38 C.F.R. § 3.307 (a) (6) (iii). Accordingly, the first and second prongs of McLendon v. Nicholson, 20 Vet. App. 79 (2006) have been met. As to the third prong of McLendon, as discussed, the NAS recently upgraded hypertension to the “sufficient” category from “limited or suggestive,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide agent exposure. See November 15, 2018, press release from NAS. In view of the above, the evidence in this case is sufficient to indicate that the Veteran’s hypertension may be related to the presumed in-service herbicide agent exposure. Therefore, the low threshold of McLendon has been met, and remand is required to obtain a competent medical examination/opinion in light of the NAS upgrade of hypertension to the “sufficient” category. 6. Service connection for bilateral eye condition is remanded. 7. Service connection for erectile dysfunction is remanded. The Veteran also contends he has a bilateral eye condition and erectile dysfunction due to his in-service herbicide agent exposure or, alternatively, secondary to his service-connected diabetes mellitus and/or hypertension. Because a decision on the remanded issue of hypertension could significantly impact a decision on the issues of bilateral eye condition and erectile dysfunction, the issues are inextricably intertwined. A remand of the claims for service connection for bilateral eye condition and erectile dysfunction would be helpful.   8. Service connection for sleep apnea is remanded. The Veteran contends his sleep apnea is related to service or, alternatively, is secondary to his service-connected allergic rhinitis. A February 2014 VA examination for the Veteran’s allergic rhinitis notes greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. A December 2017 VA examination notes not greater than 50 percent obstruction of the nasal passage on both sides. To date, the Veteran has not been afforded a VA examination to determine whether his sleep apnea is secondary to his service-connected allergic rhinitis. An opinion would be helpful in determining whether sleep apnea is related to service or the service-connected allergic rhinitis. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his claimed disabilities of lumbar spine degenerative joint disease, a bilateral knee condition, a bilateral hip condition, and a skin condition. The examiner must review the claims file. The examiner is asked to provide a response to the following: a) Are any of the claimed lumbar spine degenerative joint disease, bilateral knee, bilateral hip, and skin conditions at least as likely as not related to service, including as a result of exposure to herbicide agents in Vietnam; or, with regard to the orthopedic conditions- related to wearing heavy combat gear weighing over 75 pounds; or with respect to the onychomycosis of the bilateral toenail - due to swampy conditions in Vietnam? Provide a rationale to support the opinions. In providing the requested opinions, consider the Veteran’s description of his in-service injuries 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 injury and symptoms in service and thereafter represented the onset of his current disabilities 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 it at least as likely as not that the arthritis of the bilateral hips, lumbar spine, or bilateral knees (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? c) Are any of these lumbar spine degenerative joint disease, bilateral knee, bilateral hip, and skin conditions at least as likely as not related to in-service exposure to herbicide agents? The examiner is advised that a negative opinion cannot be based solely on the fact that the condition is not on the list of diseases that are presumptively associated with exposure to herbicide agents. Provide a rationale to support the opinions. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his hypertension, eye condition, erectile dysfunction, and sleep apnea. a) The examiner must opine whether any of these conditions are at least as likely as not related to an in-service injury, event, or disease, including his presumed exposure to herbicide agents. The examiner is advised that a negative opinion related to presumed herbicide agent exposure cannot be solely based on the absence of hypertension from VA’s list of diseases associated with exposure to certain herbicide agents found in 38 C.F.R. § 3.309 (e). b) The examiner must also opine whether Veteran’s hypertension, eye condition, and erectile dysfunction are at least as likely as not (i) proximately due to service-connected diabetes mellitus, or (ii) aggravated beyond natural progression by service-connected diabetes mellitus. c) Is the Veteran’s sleep apnea at least as likely as not (i) proximately due to his service-connected allergic rhinitis, or (ii) aggravated, i.e., worsened beyond its natural progression, by the service-connected allergic rhinitis? (Continued on the next page)   The examiner must provide a complete rationale for all proffered opinions. Regarding secondary service connection, separate opinions and rationale for proximate causation and aggravation are required. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.Aoughsten, Associate 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.