Citation Nr: 21013036 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 14-38 954A DATE: March 8, 2021 ORDER Entitlement to service connection for chronic obstructive pulmonary disease (COPD) is denied. Entitlement to service connection for bronchial asthma is denied. Entitlement to a compensable evaluation for eczematous dermatitis is denied. REMANDED Entitlement to service connection for chronic sinusitis is remanded. Entitlement to service connection for cephalgia is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to an evaluation in excess of 10 percent for left knee total arthoplasty (previously rated as left knee injury residuals) prior to August 11, 2018, in excess of 30 percent from October 1, 2019, and in excess of 60 percent from October 5, 2020 is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had COPD at any time during or approximate to the pendency of the claim. 2. The preponderance of the evidence of record is against finding that the Veteran has had bronchial asthma at any time during or approximate to the pendency of the claim. 3. The Veteran’s eczematous dermatitis has been controlled by topical medication and affects less than five percent of the entire body and less than five percent of exposed areas and has not involved treatment from corticosteroids or other immunosuppressive drugs approximating systemic therapy and does not cause disfigurement, scars, or extensive lesions. CONCLUSIONS OF LAW 1. The criteria for service connection for COPD are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for bronchial asthma are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 3. The criteria for a compensable disability rating for eczematous dermatitis have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7806 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1990 to April 1991, February 2001 to October 2001, and from November 2004 to May 2006. This matter is before the Board of Veterans’ Appeals (Board) on appeal from July 2014 and May 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In a November 2014 VA Form 9, Appeal to Board of Veterans’ Appeals, the Veteran requested to appear at a hearing before the Board. In subsequent correspondence received in March 2018, he withdrew his hearing request. The case was previously before the Board in April 2020 when it was remanded for further development. 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). COPD and Bronchial Asthma The Veteran is seeking service connection for COPD and bronchial asthma, which he contends is the result of breathing contaminated and toxic air generated by burn pits and oil fires while serving in Iraq. Service personnel records indicate that the Veteran served in Iraq in August 2005 and was awarded the Combat Infantryman Badge. The Veteran’s service treatment records are silent for any complaints, treatment, or diagnosis of asthma. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of COPD and of bronchial asthma and has not had one at any time during the pendency of the claim or recent to the filing of the claim in November 2016. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran’s VA treatment records, despite consistent treatment, consistently note that the Veteran denied any cough, wheezing, and shortness of breath. Records from the Naval Branch Health Care Albany Clinic indicate that the Veteran did not have COPD and asthma. A pulmonary function test in July 2012 was within normal limits, and July 2014, July 2015, and July 2017 records note no pulmonary disease. An October 2020 VA examiner evaluated the Veteran and determined that, despite the Veteran’s statements that he was short of breath daily, he did not have a diagnosis of a respiratory condition. The examiner indicated that a chest x-ray in October 2020 showed no acute processes and was within normal limits. The examiner stated that no diagnosis could be rendered as there were no findings, signs, or symptoms to support a diagnosis. Chest x-rays and sinus x-rays were not completed by the Veteran and the examiner had difficulty with the veracity of the Veteran’s medical history, because the examiner indicated that the Veteran asked the medical assistant administering the PFT to make sure the results were poor. While a November 2016 report from Dr. P.Y. indicates that the Veteran has COPD/bronchial asthma which was more likely than not directly and causally related to constant breathing of the contaminated and toxic air generated by burn pits and oil fires. However, there is no indication that Dr. P.Y. performed a physical examination or any diagnostic tests to confirm the presence of COPD and bronchial asthma. Instead, the statement appears to be based on the Veteran’s self-reported medical history, which is inconsistent with the other medical evidence of record, which show no complaints of or diagnosis of COPD or bronchial asthma. The Board also notes that records from Albany Primary Health, Hughston Clinic received in June 2020 list “COPD: (no answer) NO MEDICATION” in the Veteran’s past medical history. However, there was no corresponding COPD diagnosis. Consequently, the Board gives more probative weight to the treatment records and the VA examiner’s findings. While the Veteran believes he has a current diagnosis of COPD and bronchial asthma, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Service connection may only be granted for a current disability. When a claimed condition is not shown, there may be no grant of service connection. Congress specifically limited entitlement for service-connected disease or injury to cases where the incident resulted in a disability. In the absence of proof of a present disability there can be no valid claim. 38 U.S.C. § 1110, 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record does not demonstrate that the Veteran has been diagnosed with a current disability of COPD or bronchial asthma. As such, the threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for COPD and bronchial asthma must be denied. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Rating-Eczematous Dermatitis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to disability compensation has already been established and an increase in the assigned rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran is seeking a compensable rating for his eczematous dermatitis. The Veteran’s disability is rated under 38 C.F.R. § 4.118, Diagnostic Code 7806 for dermatitis or eczema. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran’s skin condition; and (2) whether the given treatment is “like” a corticosteroid or other immunosuppressive drug.” Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. Here, the evidence of record demonstrates that the predominant disability is eczematous dermatitis, as a result a result rating under diagnostic codes 7800-7805 is not applicable. VA treatment records from January 2015 and January 2016 note that the Veteran denied new rashes or skin lesions. A skin assessment in January 2016 noted no wounds, skin lesions, or rash. A November 2016 report from Dr. P.Y. indicated that the Veteran suffered significant extension of the condition with more problematic symptoms and larger area of coverage. The Veteran suffered from exfoliative lesions on his neck, back, legs, and abdomen. An area of his left neck was viewed as eczema. The Veteran underwent a VA examination in April 2017. The Veteran described having a rash on the chest, back, and legs that would come and go. Current treatment was Benadryl cream when it would flare up. The Veteran’s skin condition did not cause scarring or disfigurement of the head, face, or neck and there were no benign or malignant skin neoplasms. There were also no systemic manifestations due to any skin diseases. The Veteran was not treated with oral or topical medications in the past 12 months for skin conditions and did not have any treatments or procedures other than systemic or topical medications in the past 12 months for exfoliative dermatitis or papulosquamous disorders. The Veteran did not have any debilitating or non-debilitating episodes in the past 12 months of urticaria, primary cutaneous vasculitis, erythema multiforme, or toxic epidermal necrolysis. Physical examination found no current findings of eczematous dermatitis. There were no tumors or neoplasms and no other pertinent physical findings. The Veteran’s skin conditions did not impact his ability to work. VA treatment records from February 2017 and July 2017 note a skin assessment indicating no wounds, skin lesions, or rash. In February 2017 and May 2017, there was a right arm flexor surface with vesicular, erythematous rash. There were no noted lesions. He was assessed with a hypersensitivity reaction, poison ivy. In July 2017, the Veteran had no lesions consistent with malignancy and no rashes were noted. In July 2018, December 2018 and June 2019, a skin assessment indicated no wounds, skin lesions, or rash. The Veteran also denied any skin lesions. In December 2019, a skin assessment indicated no wounds, skin lesions, or rash, and no rashes were noted on examination. In the April 2020 remand, the Board directed that the Veteran be contacted and asked to complete a medical release for the private treatment records for the private dermatologist he indicated he was seeing during February 2017 VA treatment. The RO sent the Veteran a letter in May 2020 requesting that he complete and return a VA Form 21-4142 for the complete treatment records for the private dermatologist he indicated he was seeing during February 2017 VA treatment. The Veteran returned a VA Form 21-4142 in June 2020 but did not include information for the private dermatologist. The Board stresses that the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). A Veteran must cooperate when asked for information that is essential in obtaining putative evidence and a refusal to do so denies VA evidence which might have helped establish the claim. Id. Therefore, it was incumbent upon the Veteran to cooperate with the VA in developing his claim and the Board is unable to consider it in evaluating his claim. As such, the Board finds that the RO substantially complied with the directives in the April 2020 remand with regard to this claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In August 2020 VA treatment records, the Veteran’s skin was warm and dry, and no rashes were noted. A skin assessment indicated no wounds, skin lesions, or rash. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the pre-August 13, 2018, regulations because the Veteran’s eczematous dermatitis does not more nearly approximate at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. The VA examination and the VA treatment records in fact, mostly show that there were no wounds, skin lesions, or rashes, and that the Veteran used topical cream for treatment. Although the November 2016 report from Dr. P.Y. indicated that the Veteran had eczema with a larger area of coverage, it is of diminished weight as it is inconsistent with other medical evidence of record. In determining whether evidence submitted is credible, VA may consider internal consistency, facial plausibility, and consistency with other evidence. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995). The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the August 13, 2018, regulations because the Veteran’s eczematous dermatitis does not more nearly approximate characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12- month period. Although the November 2016 report from Dr. P.Y. indicated that the Veteran suffered from exfoliative lesions on his neck, back, legs, and abdomen, this statement is of diminished weight as it is inconsistent with other medical evidence of record. Id. Also, as indicated in VA treatment records from January 2015, January 2016, July 2018, December 2018, and June 2019, the Veteran denied any new rashes or skin lesions. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). While the Veteran is competent to report his dermatological symptoms such as rashes and irritation, as well as his skin treatment, he is not competent to make the requisite clinical findings under the relevant rating criteria, such as the area of his skin symptoms or whether his therapy is “systemic.” 38 C.F.R. § 4.118, Diagnostic Code 7806; see also Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although the Veteran contends that his skin condition warrants a higher rating than that which is assigned, it is ultimately VA adjudicators’ role to apply relevant regulations and assign disability ratings. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a compensable rating for eczematous dermatitis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND Chronic Sinusitis In the April 2020 remand, the Board directed that the Veteran be afforded a VA examination regarding his claim for service connection for chronic sinusitis. The examiner was asked to provide an opinion as to whether it was at least as likely as not that the Veteran’s chronic sinusitis was related to his active service. The Veteran underwent a VA examination in October 2020. The examiner found that it was less likely than not that the Veteran’s chronic sinusitis was related to his active service, because he had no evidence of sinusitis on his x-rays and therefore there was no evidence of sinusitis. However, the examiner did the discuss the significance, if any, of the examiner’s summary in the September 2001 report of Medical History, which stated that the Veteran had chronic sinusitis, December 2006 VA treatment records, which noted problems with draining sinuses, and February 2009 records which provide an impression of sinusitis. VA treatment records from July 2016 and July 2017 indicate that the Veteran has ethmoid sinus disease. VA treatment records also list sinusitis under the Veteran’s problem list. The Board notes that the requirement for a current disability is satisfied if there is evidence of the disability at any time during the Veteran’s appeal. McClain v. Nicholson, 21 Vet. App. 319 (2008). Remand for a new VA examination to determine whether the Veteran has a diagnosis of chronic sinusitis is warranted. Cephalgia In the April 2020 remand, the Board directed that the Veteran be afforded a VA examination regarding his claim for service connection for cephalgia. The examiner was asked to provide an opinion as to whether it was at least as likely as not that the Veteran’s cephalgia was related to his active service, and whether it was at least as likely as not proximately due to or aggravated by his chronic sinusitis. The Veteran underwent a VA examination in October 2020. The examiner found that the Veteran had migraine headaches, including migraine variants. The examiner opined that it was less likely than not that the Veteran’s cephalgia was related to his active service, because there was nothing noted in the service records or the separation examination that discussed headaches. The examiner also opined that cephalgia was less likely than not proximately due to or aggravated by chronic sinusitis, because the Veteran did not go for a sinus x-ray as ordered so the examiner could not make any decision about whether he has sinus headaches. However, the examiner did not discuss service treatment records which include a July 1995 Report of Medical History, which indicated that the Veteran suffered from blurred vision for the past five years associated with headaches. Also, as the Veteran’s claim for service connection for chronic sinusitis is being remanded for a new examination, remand of this claim for a new VA examination is warranted. Sleep Apnea The Veteran is seeking service connection for sleep apnea, which he claims is secondary to his service-connected posttraumatic stress disorder (PTSD). In the April 2020 remand, it was directed that a supplemental opinion be obtained with a complete rationale regarding whether it was at least as likely as not that the Veteran’s sleep apnea was caused or aggravated by his service-connected PTSD. A VA medical opinion was obtained in October 2020. The clinician opined that sleep apnea was less likely than not proximately due to or aggravated by PTSD. The rationale provided was that many people with PTSD have difficulty sleeping due to nightmares, insomnia, etc., and are sent for a sleep study and found to have sleep apnea. However, sleep apnea is due to obstruction of the posterior pharynx, a mechanical problem, according to Dr. K. Strohl in the Merck Manuel. Therefore, PTSD did not cause or aggravate the Veteran’s sleep apnea. The clinician, despite rendering a negative opinion, appears to indicate some relationship between PTSD and sleep apnea. Also, the clinician did not provide a rationale regarding why the Veteran’s sleep apnea was less likely than not aggravated by the service-connected PTSD. The clinician stated that sleep apnea is due to obstruction of the posterior pharynx but did not discuss aggravation. An adequate medical opinion regarding secondary service connection must address causation and aggravation separately. El-Amin v. Shinseki, 26 Vet. App. 136 (2013); see also 38 C.F.R. § 3.310(b). As such, remand for another medical opinion is necessary. Left Knee Regarding the Veteran’s claim for an increased rating for his service-connected left knee, treatment records from Albany Primary Health, Hughston Clinic were obtained in June 2020. Included in the records were records from his 2018 knee replacement surgery, and they are up till November 2019. VA treatment records obtained in September 2020 include August 2020 treatment records which indicate continued pain and referral back to the Hughston Clinic for further evaluation. As treatment records are relevant in evaluating the current severity of the Veteran’s disability, remand is needed to obtain updated private treatment records. All Issues Also, while on remand, updated VA treatment records should be obtained and associated with the claims file. The Veteran should also be afforded an opportunity to identify any relevant outstanding private treatment records and any other relevant evidence pertaining to his claims being remanded. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for the complete treatment records from Albany Primary Health, Hughston Clinic from November 2019 to the present. Also provide the Veteran an opportunity to identify any relevant outstanding private treatment records and any other relevant evidence pertaining to his claims being remanded. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. Obtain the Veteran’s VA treatment records for the period from September 2020 to the present. 3. After completing the above development, schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of his chronic sinusitis. The electronic claims file must be made available to the examiner, and the examiner must specify in the opinion that the file has been reviewed. Based on review of the pertinent evidence of record, and any tests, studies or examinations, the examiner must provide the following opinions: a) Determine whether the Veteran has a current diagnosis of chronic sinusitis. The examiner must consider VA treatment records from July 2016 and July 2017 that indicate that the Veteran has ethmoid sinus disease, and that VA treatment records list sinusitis under the Veteran’s problem list. The examiner is advised that even if a disability subsequently resolves during the appeal period, service connection may still be awarded if a disability is diagnosed at the time the claim was filed or during the pendency of the claim. McClain, 21 Vet. App. at 321. b) Then, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that a diagnosis of chronic sinusitis is related to the Veteran’s active service, to include the examiner’s summary in the September 2001 report of Medical History, which stated that the Veteran had chronic sinusitis. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 4. Also schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of his cephalgia. The electronic claims file must be made available to the examiner, and the examiner must specify in the opinion that the file has been reviewed. Based on review of the pertinent evidence of record, and any tests, studies or examinations, the examiner must provide the following opinions: a) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s cephalgia was incurred in or related to his active service. The examiner must discuss service treatment records which include a July 1995 Report of Medical History, which indicated that the Veteran suffered from blurred vision for the past five years associated with headaches. b) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s cephalgia was caused by his chronic sinusitis. c) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s cephalgia was aggravated (i.e., any worsening of the condition beyond its natural progression) by his chronic sinusitis. In providing the opinions in b and c, the examiner must consider VA treatment records from December 2006 which note that the Veteran would get frequent headaches from his draining sinuses. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 5. Obtain a supplemental medical opinion from a medical professional with the appropriate expertise with regard to the Veteran’s claim of entitlement to service connection for sleep apnea. The electronic claims file, including a copy of this Remand, must be made available to and reviewed by the examiner. After reviewing the claims file, the clinician is asked to answer the following questions: a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s sleep apnea was caused by his service-connected PTSD. b) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s sleep apnea was aggravated (i.e., any worsening of the condition beyond its natural progression) by his service-connected PTSD. The clinician is reminded that an adequate medical opinion regarding secondary service connection must address causation and aggravation separately. El-Amin v. Shinseki, 26 Vet. App. 136 (2013); see also 38 C.F.R. § 3.310(b). A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. Mills Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Bonnie Yoon, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.