Citation Nr: 21009229 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 10-09 815 DATE: February 22, 2021 ORDER Entitlement to service connection for a heart condition, to include atrial fibrillation, is granted. Entitlement to service connection for sleep apnea is granted. Entitlement to service connection for headaches is granted. Entitlement to a rating of 70 percent, but no higher, since July 15, 2008 for service-connected PTSD with major depression is granted. REMANDED Entitlement to service connection for a dental condition, including dry mouth (xerostomia), is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a thoracolumbar spine disability, including degenerative spondylosis, is remanded. Entitlement to service connection for a right wrist disability, to include carpal tunnel syndrome, is remanded. Entitlement to service connection for a left wrist disability, to include carpal tunnel syndrome, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran’s favor, his atrial fibrillation, sleep apnea, and headaches are proximately due to his service-connected PTSD with major depression. 2. Granting the Veteran the benefit of reasonable doubt, the severity, frequency, and duration of his PTSD symptoms more closely approximate occupational and social impairment with deficiencies in most areas throughout the appeal period but do not result in total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for atrial fibrillation as secondary to PTSD with major depression are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for sleep apnea as secondary to PTSD with major depression are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 3. The criteria for service connection for headaches as secondary to PTSD with major depression are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for a disability rating of 70 percent, but no higher, since July 15, 2008 for PTSD with major depression have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1970 to November 1972, with additional periods of service in the National Guard and Army Reserve, discussed further below. This matter is before the Board of Veterans’ Appeals (Board) on appeal from August 2007, March 2009, March 2015, and September 2017 rating decisions. As an initial matter, the Board notes the Veteran’s claims for entitlement to service connection for sleep apnea, headaches, disabilities involving the spine and right knee, carpal tunnel syndrome, dry mouth, and a dental condition were referred to the Agency of Original Jurisdiction (AOJ) for adjudication by the Board in September 2015. These issues are currently on appeal from a September 2017 rating decision. A review of the record shows that the claims regarding right knee and spine disabilities were initially denied in and not appealed from June 1998 rating decision. A later March 2009 rating decision denied a request to reopen the claims for service connection for the right knee and spine, and also denied service connection for sleep apnea and bilateral wrist disabilities. These issues were not appealed from this March 2009 denial. As the Board noted in the September 2015 remand with regard to the Veteran’s claim for service connection for his left knee disability, the new evidence received since these prior decisions includes service treatment records (STRs) submitted in October 2009 that existed but were not in the record at the time of the denials. When new service records that existed and had not been associated with the claims file are received following denial of a claim for entitlement to service connection, as is the case here, VA will reconsider the previously denied claims. 38 C.F.R. § 3.156(c). Therefore, reopening of the service connection claims for sleep apnea and disabilities affecting the bilateral wrists, right knee, and spine is not necessary, and the June 1998 and March 2009 denials will be reconsidered de novo in light of the new evidence. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence of (1) a current disability; (2) an 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Entitlement to service connection for a heart condition, to include atrial fibrillation, as secondary to service-connected PTSD with major depressive disorder The Veteran contends that his heart condition, diagnosed as atrial fibrillation, is related to his service-connected PTSD disability with major depression. The Veteran’s VA treatment records and an October 2014 VA examination report show the Veteran has a current diagnosis of atrial fibrillation. The October 2014 VA examiner opined that this diagnosed disability was less likely than not caused by PTSD; however, as rationale, the examiner merely provided a conclusory statement that PTSD does not cause atrial fibrillation, followed by a list of possible causes without any discussion of the Veteran’s history or the evidence of record. Another VA examiner was asked to provide a supplemental medical opinion in February 2020 more thoroughly addressing secondary causation and aggravation, but this second examiner provided the exact same list of possible causes drawn from the same source as the sole rationale for finding that the Veteran’s atrial fibrillation is unrelated to his PTSD, again without any discussion of the Veteran’s medical history or individual circumstances. These conclusory opinions clearly lack adequate rationale and are therefore entitled to no probative weight. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In support of his claim, the Veteran submitted a private medical opinion by a physician, M.B., in May 2020. In this opinion, M.B. initially addressed the Veteran’s history of chronic atrial fibrillation with pacemaker implantation in January 2016, as well as his history of treatment for PTSD with major depression. She then cited a study from September 2019, which has been submitted for inclusion in the record, which found an association between PTSD and a higher incidence of atrial fibrillation. Based on the Veteran’s history and this research, she opined that it is at least as likely as not that the Veteran’s atrial fibrillation is related to his PTSD and associated symptoms. The private physician’s report is competent and credible, as it was based on a review of the Veteran’s medical history and supported by reference to relevant medical literature; therefore, it is entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Based on a review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current atrial fibrillation is proximately due to his service-connected PTSD with major depression. Accordingly, after resolving the benefit of reasonable doubt in favor of the Veteran, the Board finds that service connection for atrial fibrillation is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for sleep apnea secondary to service-connected PTSD The Veteran contends his obstructive sleep apnea is related to his service-connected PTSD with major depression. A VA examiner in October 2009 reported the Veteran has diagnosed sleep apnea with onset about 12 years prior. No nexus opinion was provided as part of this examination. In May 2020, the Veteran submitted a sleep apnea disability benefits questionnaire (DBQ) completed by a private physician, M.B., who confirmed the diagnosis of obstructive sleep apnea prior to 2009. In an accompanying opinion, M.B. discussed the Veteran’s history of sleep apnea and PTSD symptoms, noting the impact of these symptoms on his sleep. She then cited multiple studies showing that PTSD and other psychiatric disorders that impair sleep patterns are commonly associated with and co-morbid with obstructive sleep apnea. Based on these studies and the Veteran’s history, the examiner opined that it is as likely as not that the Veteran’s PTSD and medication prescribed for treatment of PTSD resulted in the development of his obstructive sleep apnea. She acknowledges that the Veteran’s obesity is also a significant contributing factor, though she indicates the degree of contribution of each could not be separated and his sleep apnea symptoms have not improved despite recent significant weight loss. The private physician’s report is competent and credible, as it was based on a review of the Veteran’s medical history and supported by reference to relevant medical literature; therefore, it is entitled to significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Based on the probative medical evidence submitted by the Veteran, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current obstructive sleep apnea is proximately due to service-connected PTSD. Accordingly, after resolving the benefit of reasonable doubt in favor of the Veteran, the Board finds that service connection for sleep apnea is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for headaches secondary to service-connected PTSD The Veteran contends that his chronic headaches are related to his service-connected PTSD with major depression. The Veteran’s medical records show he has suffered from chronic headaches for years, with a November 1995 VA examination recording complaints of frontal headaches. An October 2009 VA examination again notes chronic headaches; however, the examiner indicated these began in 2008. Most recently, the Veteran submitted a May 2020 headache DBQ from a private physician, M.B., who diagnosed the Veteran with tension headaches occurring 10 to 15 days per month, with escalating episodes up to three times per week requiring him to lie down for at least 45 minutes at a time. The Veteran reported that headaches are mainly brought about by periods of stress, anxiety, and depression, with increases in these symptoms resulting in more severe headaches. M.B. cited research showing an association between both migraine and non-migraine headaches and depression and anxiety disorders. She indicates studies have shown psychological stress and headaches are closely related with psychological stress contributing to headache disorder onset and exacerbation. Based on this evidence, she opined that it was at least as likely as not that the Veteran’s service-connected PTSD caused his headaches disability. The private physician’s report is competent and credible, as it was based on a review of the Veteran’s medical history and supported by reference to relevant medical literature; therefore, it is entitled to significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Based on this, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current headaches are proximately due to service-connected PTSD with major depressive disorder. Accordingly, after resolving the benefit of reasonable doubt in favor of the Veteran, the Board finds that service connection for headaches is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. Where service connection has been granted and the assignment of an initial evaluation is disputed, separate evaluations may be assigned for different periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. The Veteran contends that symptoms and resulting impairment from his service-connected PTSD warrant in excess of his current 50 percent rating. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a “holistic analysis” that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran’s psychiatric symptoms caused the level of impairment required for a disability rating in excess of 50 percent since the Veteran filed his claim for benefits on July 15, 2008. A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. In a VA examination report before the appeal period from September 2006, the examiner noted that the Veteran attended the examination with fair grooming and hygiene, appearing sleepy during the examination. Affect was sad and overall mood depressed. Thinking was slow, disorganized and rambling, and it was difficult to get the Veteran to answer questions. He presented as preoccupied with events that happened in Vietnam, and he had difficulty focusing. His self-esteem was low, and judgment was diminished by depression, leading to social isolation. Though the examiner saw need for increased treatment, the likelihood of significant change in the Veteran’s condition was considered low. The examiner indicated that the Veteran’s condition resulted in an inability to maintain friendships and employment. A December 2008 PTSD examination report noted reports from the Veteran of severe daily depression, nightmares, and intrusive thoughts of Vietnam service. The Veteran also reported two periods of hospitalization for PTSD in July and August 2008. The Veteran reported a decline in his condition over the past year. The Veteran described himself as a loner, indicating he was terminated from his job in 1995 and unable to continue working because of sleep impairment, lack of energy, and large amount of medication he had to take. He also reported severe headaches, memory problems, diminished concentration, and inability to focus. The examiner noted reports of mild auditory hallucinations a couple times per day. The Veteran reported irritability and a prior history of suicidal thoughts, though none recently. He generally was not able to maintain minimal personal hygiene, describing long periods without showering or bathing, which the examiner confirmed based on the Veteran’s appearance at the examination. He also exhibited severe depression, moderate anxiety symptoms, occasional impulse control issues, and sleep impairment. The examiner concluded that the Veteran’s PTSD and side effects of medication contributed to his unemployment and cause interference with performance of basic activities of daily life like grooming and hygiene. At an October 2009 VA examination, the Veteran reported experiencing intrusive memories, suicidal thoughts, depression, nervousness, nightmares, sleep disturbances, poor concentration, and excessive anger and irritation. He denied any plans or intent to act on suicidal thoughts. The Veteran’s affect was sad and slightly irritable with overall depressed mood. Relationships with others were described as poor in quality with a low frequency of contact. The examiner indicated the Veteran’s symptoms were moderate to severe with impaired social relationships, judgment , mood, and range of activities, with deficiencies in most areas of occupational and social functioning due to suicidal ideation, near continuous depression, impaired impulse control, neglect of personal appearance, difficulty adapting to stressful circumstances, and an inability to establish and maintain effective relationships. The Veteran submitted a private PTSD evaluation from a licensed psychologist in June 2015. The report from this evaluation indicated the Veteran experienced impairment with occupational and social impairment with deficiencies in most areas due to symptoms such as: intrusive and distressing memories and dreams related to in-service trauma; avoidance of stimuli related to trauma; difficulty falling asleep; irritability; difficulty concentrating; hypervigilance; exaggerated startle response; depressed mood; anxiety; suspiciousness; near-continuous panic or depression; chronic sleep impairment; memory loss; flattened affect; circumstantial; circumlocutory; or stereotyped speech; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; neglect of personal appearance and hygiene; and intermittent ability to perform activities of daily living. The Veteran denied hallucinations and suicidal ideation. VA treatment records show intermittent psychiatric therapy over the course of the period on appeal, though the Veteran has been consistently prescribed medication for treatment of his symptoms. These treatment notes reflect consistent reports of depression and sleep impairment, as well as frequent flashbacks of combat service with accompanying increases in irritability. The Veteran has generally denied experiencing hallucinations, and suicidal ideation has been generally denied in most recent reports. Review of these treatment records shows reports of symptoms generally consistent with or less severe than those reported during the exams of record, with decreased symptoms typically attributed to medication use. In statements submitted throughout the appeal period, the Veteran has asserted that his PTSD has progressively worsened over time since he was initially diagnosed, with his depression becoming severe and nearly constant. The Veteran reports flashbacks, sometimes with auditory hallucinations, as well as thoughts of suicide without intent or plan. He reports that he does not take showers unless his spouse tells him to, and he generally avoids social interactions, preferring to be alone. He generally does not care about most aspects of his life and does not find enjoyment in most activities. Though reports from the beginning of the appeal period indicated he continued to lead scout groups and found enjoyment in this activity, more recent statements indicate he has been forced to cease this activity, as well. He maintains that he is able to perform daily activities of living only with the assistance of his wife. An April 2020 statement from his wife supports these accounts, describing symptoms of impaired memory, lack of motivation, mood swings, frustration, anger, stress, isolation, impaired sleep, poor hygiene, and general depression. After resolving the benefit of reasonable doubt in favor of the Veteran, the Board finds the severity, frequency, and duration of the Veteran’s symptoms more closely approximate the symptoms contemplated by a 70 percent rating. At no time, however, have the Veteran’s symptoms been severe enough to result in total impairment of social occupational functioning. The Veteran has reported auditory hallucinations in some statements and at his December 2008 examination; however, the examiner described these symptoms as mild and the Veteran has denied experiencing hallucinations in more recent examinations and treatment records. Based on these reports, even assuming the Veteran experiences persistent auditory hallucinations of some nature, the Veteran’s PTSD symptoms considered together with these hallucinations do not result total occupational and social impairment, as discussed further below. With respect to social impairment, the Board notes that the Veteran generally isolates from others and is unable to maintain most relationships, though he has been able to maintain his relationship with his wife. He has been consistently described during the appeal period as unable to establish and maintain effective relationships, but his demeanor and behavior during exams and in treatment records does not reflect gross impairment of thought processes or communication or grossly inappropriate behavior. The evidence of record further contains reports of suicidal ideation early during the appeal period shortly after he filed his claim, both during examinations and in a statement from February 2010. More recent reports deny continuing suicidal ideation; however, these more recent statements and examination reports indicate the Veteran experiences near-continuous depression affecting his ability to function independently, appropriately, and effectively. He also exhibits impaired impulse control, neglect of personal appearance and hygiene, and difficulty adapting to stressful circumstances. He reports impaired memory and concentration, though the preponderance of the evidence, including the Veteran’s own statements, fail to show this memory loss is so severe that he cannot remember his own name or the names of close relatives. There are no indications in the record that the Veteran is a persistent danger to himself or others or that he has exhibited disorientation to time or place. In summary, though the Veteran’s symptoms have been severe throughout the appeal period, they have not resulted in total occupational and social impairment. For these reasons, the Board finds that the Veteran has met the criteria for a 70 percent rating, but no higher, throughout the appeal period; therefore, entitlement to a 70 percent evaluation for PTSD with major depressive disorder since July 15, 2008, the date of his claim for an increased rating, is warranted. REASONS FOR REMAND 1. Entitlement to service connection for a dental condition, including dry mouth The Veteran contends he has dry mouth with associated dental conditions, such as loss of teeth and abscesses, as the result of medications taken for his service-connected PTSD with major depressive disorder. The medical evidence of record clearly shows that the Veteran has been diagnosed with xerostomia, which both VA and private physicians have stated is at least partially due to medication he has taken over past decades. This medical evidence also shows that this xerostomia has resulted in the loss of several teeth and numerous dental infections and abscesses. While the medical evidence of record shows the Veteran has xerostomia related to medication, the Board finds there is not adequate evidence to reach a decision for the Veteran’s claim. The Veteran’s VA treatment records contain notes regarding dozens of medications the Veteran has taken since separation from service, including medications taken for both service-connected and non-service-connected disabilities. The medical opinions that state the Veteran’s xerostomia is the result of medication fail to clearly identify which specific medications caused his xerostomia, including whether xerostomia is a known side effect of medications taken for PTSD, depression, and associated symptoms. The Board also notes the Veteran takes medications for conditions granted service connection in this decision and those being remanded for additional development. A remand is therefore necessary to determine if xerostomia is a side effect specifically associated with any of the medications used by the Veteran to treat symptoms of one or more of his service-connected disabilities or a claimed condition. The Board notes that a claim for service connection for a dental condition is also considered a claim for VA outpatient dental treatment. Mays v. Brown, 5 Vet. App. 302, 306 (1993). 38 C.F.R. § 3.381 clarifies that VBA will adjudicate a claim for service connection of a dental disorder for treatment purposes after VHA determines that a veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161 and asks that VBA make a decision on relevant questions. 38 C.F.R. § 3.381(a). It does not appear that VHA made a decision regarding the Veteran’s eligibility for dental treatment. Thus, the Board finds that a remand is necessary so that VHA may adjudicate the issue of service connection for dental treatment purposes in the first instance. 2. Entitlement to service connection for a left knee disability is remanded. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The most recent VA examination opinion of record from April 2020 states that the Veteran’s left knee disability was not at least as likely as not the direct result of an injury sustained in a period of active duty for training (ACDUTRA) during the Veteran’s service in the Army Reserve sometime between 1978 and 1981. The examiner also opined the Veteran’s left knee condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury. During the period at issue, the record shows the Veteran had three periods of ACDUTRA in March to April 1979, August 1980, and August to September 1981. The Veteran’s initial knee injury occurred outside of active service in 1978 and was followed by removal of a Baker’s cyst in November 1978. This was later followed by surgery to repair a meniscus tear in March 1981, and a diagnosis of degenerative arthritis later that year. The examiner’s rationale for finding that the Veteran’s left knee was not aggravated during this period is that there was a lone mention of knee stiffness in August 1981 without further complaints until 1983. The examiner takes this as evidence that the Veteran’s reported pain and stiffness during training was self-limited and acute. The examiner’s rationale appears to be based on the sole report of pain and stiffness noted in the Veteran’s service treatment records from this period, yet fails to account for any of the Veteran’s personal statements, supporting statements from his wife, additional records of private treatment, and assessments performed by his employer and contracted medical providers during this period. Notably, a February 1990 assessment of the Veteran’s knee provides a thorough timeline of medical treatment records from this period, indicating numerous treatments for the Veteran’s left knee near and between periods of training. This includes a private treatment record from September 1981 only days after the end of a period of ACDUTRA showing complaints of pain, discomfort, and swelling with enough degenerative arthritis that, given the Veteran’s weight, he could not tolerate much stress to the knee joint. This report contradicts the VA examiner’s finding that the Veteran was first assessed with degenerative changes to the knee in 1983. Private records also show the Veteran called his private treatment provider in December 1982 complaining of pain following training during a period of reserve duty. The examiner similarly failed to address the timing of the Veteran’s surgical interventions despite citing them as a source of the Veteran’s pain, including the fact that the Veteran’s March 1981 arthroscopy and accompanying surgery to address his torn posterior lateral meniscus occurred between periods of training, each of which the Veteran contends included training injuries that increased the severity of his left knee symptoms. The Board also notes an earlier claim evaluation for employee benefits from December 1985 included a review of the Veteran’s medical history that identified his military training as one of multiple causative elements of the Veteran’s knee condition, describing flares of symptoms during and after periods of military training. As the April 2020 VA examiner’s opinion is supported by rationale that does not reflect full consideration of the Veteran’s medical history and available records, including lay statements and contemporaneous medical records, the Board finds the opinion is inadequate. A remand is therefore necessary to obtain a new opinion. 3. Entitlement to service connection for a right knee disability is remanded. 4. Entitlement to service connection for a thoracolumbar spine disability, including degenerative spondylosis, is remanded. 5. Entitlement to service connection for a right wrist disability, to include carpal tunnel syndrome, is remanded. 6. Entitlement to service connection for a left wrist disability, to include carpal tunnel syndrome, is remanded. 7. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. The record reflects that the Veteran’s statements and medical evidence of record raise the issue of whether the Veteran’s right knee, spine, and bilateral wrist disabilities are secondary to his left knee disability. For this reason, the Board finds that the adjudication of the matter of service connection for these disabilities must be deferred as they are inextricably intertwined with the left knee issue being remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a “significant impact” upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). The Board likewise finds the TDIU claim is inextricably intertwined with the remanded issues above, as decisions on those claims may have a significant impact on the Veteran’s entitlement to TDIU. The matters are REMANDED for the following action: 1. Obtain a medical opinion regarding the nature and etiology of any xerostomia (dry mouth). The examiner must opine whether it is at least as likely as not proximately due to or aggravated beyond its natural progression by medications taken by the Veteran to treat his service-connected PTSD with major depressive disorder. If the examiner finds the Veteran’s xerostomia is caused or aggravated by medications taken by the Veteran for some condition other than PTSD with major depressive disorder, the examiner should indicate which medications contribute to the xerostomia and what conditions the are used to treat. The examiner’s report must include a complete rationale for the opinion. 2. Provide VCAA notice for the issue of service connection for a noncompensable dental disorder for the purpose of obtaining VA outpatient dental treatment under 38 C.F.R. § 17.161. 3. After obtaining any additional evidence pertinent to the issue on appeal, as well as developing the claim in any matter deemed appropriate, the AOJ should follow appropriate procedures for VHA to adjudicate Class eligibility in the first instance in accordance with 38 C.F.R. § 3.381. See 38 C.F.R. § 17.161. 4. Obtain a new medical opinion regarding the nature and etiology of any left knee disability. The Veteran should only be scheduled for a new examination if deemed necessary by the selected examiner. The examiner must opine whether the Veteran’s left knee disability, which existed prior to service, at least as likely as not increased in severity during a period of active service for training. If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide a reason for doing so. The fact that his report of symptoms is not corroborated by contemporaneous medical treatment records is not, by itself, a sufficient reason to reject the Veteran’s report of symptoms capable of lay observation. The examiner must address the contemporaneous accounts of the Veteran’s disability, including private medical records and assessment performed on behalf of the Veteran’s employer, in additional to service treatment records. This evidence includes, but is not limited to: (a.) Medical records documenting the Veteran’s initial knee injury in 1978; (b.) Records addressing removal of a Baker’s cyst in November 1978; (c.) Evidence documenting surgery to repair a meniscus tear in March 1981; (d.) Treatment records showing a diagnosis of degenerative arthritis in 1981; (e.) Private treatment records from September 1981, shortly after a period of ACDUTRA, documenting complaints of knee pain and other symptoms; (f.) Private records indicating a December 1982 call from the Veteran to his doctor complaining of knee pain; and (g.) A February 1990 orthopedic assessment completed for the Veteran’s employer documenting prior treatment of the Veteran’s knee. The examiner’s report must include a complete rationale for the opinion. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issues of entitlement to service connection for right knee, spine, and bilateral wrist disabilities, as well as entitlement to TDIU. If the benefit sought is not granted to the Veteran’s satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Pitman, 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.