Citation Nr: 21013118 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 17-03 239 DATE: March 8, 2021 ORDER New and material evidence not having been received, the request to reopen a claim for entitlement to service connection for chronic obstructive pulmonary disease (COPD) is denied. New and material evidence not having been received, the request to reopen a claim for entitlement to service connection for residuals of a right hamstring pull is denied. Entitlement to service connection for a bilateral hand disability is denied. Entitlement to service connection for a bilateral arm disability is denied. Entitlement to service connection for a bilateral leg disability (other than residuals of a right hamstring pull) is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) with major depressive disorder and adjustment disorder is granted. REMANDED Entitlement to service connection for bilateral pes planus, claimed as a bilateral foot disability, is remanded. Entitlement to service connection for sleep apnea, to include as secondary to service-connected acquired psychiatric disorder, is remanded. Entitlement to service connection for diabetes mellitus, type 2, to include as secondary to service-connected acquired psychiatric disorder, is remanded. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, type 2, and/or service-connected acquired psychiatric disorder, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus, type 2, and/or service-connected acquired psychiatric disorder, is remanded. Entitlement to an initial rating higher than 10 percent for dermatitis is remanded. FINDINGS OF FACT 1. A February 2014 rating decision denied the claims for entitlement to service connection for COPD and residuals of a right hamstring pull; the Veteran did not complete a substantive appeal to that decision, and it is final. 2. The evidence received since the February 2014 rating decision pertinent to the claims for service connection for COPD and residuals of a right hamstring pull is cumulative and redundant, does not relate to an unestablished fact necessary to substantiate the claims, and does not raise a reasonable possibility of substantiating the claims. 3. The preponderance of the evidence is against finding that a bilateral hand disability 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 a bilateral arm disability began during active service or is otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that a bilateral leg disability (other than residuals of a right hamstring pull) began during active service or is otherwise related to an in-service injury or disease. 6. Resolving all reasonable doubt in his favor, the Veteran has a diagnosis of PTSD with major depressive disorder and adjustment disorder that is causally or etiologically due to service. CONCLUSIONS OF LAW 1. A February 2014 rating decision that denied the claims for entitlement to service connection for COPD and residuals of a right hamstring pull is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. Evidence received since the February 2014 rating decision is not new and material, and the Veteran’s claims for service connection for COPD and residuals of a right hamstring pull are not reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 3. The criteria for service connection for a bilateral hand disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a bilateral arm disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a bilateral leg disability (other than residuals of a right hamstring pull) are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for PTSD with major depressive disorder and adjustment disorder have been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from June 1987 to September 1987 and from December 1990 to December 1992. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from February 2014 and June 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board. The requested hearing was conducted in March 2019 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In June 2019, the Board remanded the claims of entitlement to service connection for bilateral hearing loss, tinnitus, an acquired psychiatric disorder, to include PTSD with anxiety and depression, sleep apnea, hypertension, erectile dysfunction, diabetes mellitus, type 2, and entitlement to an increased rating for dermatitis, for additional development. The claims for entitlement to service connection for bilateral hearing loss and tinnitus were granted in a January 2020 rating decision, and as such, these issues are no longer on appeal. The Veteran also completed a substantive appeal for the issues of entitlement to service connection for COPD, residuals of a hamstring pull, a right hand disability, a right arm disability, a left hand disability, a left arm disability, left foot disability, right foot disability, sleep apnea, hypertension, erectile dysfunction, and diabetes mellitus, type 2. The Board notes that the Veteran requested a hearing before the Board for these issues but withdrew that request in November 2020. The Veteran was initially represented by an attorney in this appeal. In October 2020, after the claims were certified to the Board in March 2020, the attorney notified VA that he wished to withdraw from the Veteran’s case. Given the circumstances described by the attorney, the Board finds that the representative has shown good cause for withdrawal. The withdrawal letter was sent to the Veteran and notified him of the withdrawal. Accordingly, the motion to withdraw is granted. 38 C.F.R. § 20.608 (b)(2). VA has not received a new VA Form 21-22a, Appointment of Individual as Claimant’s Representative from the Veteran. Petitions to Reopen 1. Whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for COPD. 2. Whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for residuals of a right hamstring pull. The Veteran seeks to reopen his previously denied claims for entitlement to service connection for COPD and residuals of a right hamstring pull. Notwithstanding determinations by the RO that new and material evidence has or has not been received to reopen the Veteran’s claims, it is noted that on its own, the Board is required to determine whether new and material evidence has been presented. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (holding that the Board has a legal duty under 38 U.S.C. §§ 5108 and 7105, to address the question of whether new and material evidence has been presented to reopen a previously denied claim); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. The Court has elaborated on what constitutes “new and material evidence.” New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and it must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). Only evidence presented since the last final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273, 283 (1996). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Claims for entitlement to service connection for COPD and residuals of a right hamstring pull were last denied in February 2014 rating decision on the basis that there was no evidence of a current diagnosis of COPD, and no evidence of a link between COPD and service or residuals of a right hamstring pull and service. Evidence received since the rating decision consists of numerous medical records and documents. Although the Veteran submitted various treatment records, no new evidence has been received pertaining to a diagnosis of COPD or linking his claimed disorders to his time in service. As such, the Board is unable to conclude that this evidence constitutes new and material evidence to reopen the claims of entitlement to service connection for COPD and residuals of a right hamstring pull. Therefore, the Board has no alternative but to conclude that the additional evidence received in this case does not relate to an unestablished fact necessary to substantiate the claims and thus is not material. It is not material because it does not indicate that the Veteran currently suffers from COPD or residuals of a right hamstring pull because of his time in service, and therefore does not raise a reasonable probability of substantiating the claims. 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). Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The theory of continuity of symptomatology is an alternative route to establish service connection for specific chronic diseases and can only be used in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 4 (1990). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for a bilateral hand disability. 4. Entitlement to service connection for a bilateral arm disability. 5. Entitlement to service connection for a bilateral leg disability (other than right hamstring pull). The Veteran seeks entitlement to service connection for a bilateral hand disability, bilateral arm disability, and bilateral leg disability. The Board notes that the RO separated out each individual finger, hand, arm and leg into separate claims; however, for purposes of this decision, the Board has grouped them together. Additionally, the Veteran originally claimed entitlement to service connection for a left hand disability and right hand disability, not for individual fingers. See, e.g., October 2018 VA Form 21-526EZ. Claims for these disabilities were received in October 2018. Service treatment records do not contain any particular complaints, treatment or diagnoses of hand, arm, or leg disorders. On the November 1992 report of medical history for separation, the Veteran denied having any current or past hand, arm, or leg injuries/disorders and his separation examination did not note any abnormalities pertaining to the hands, arms, or legs. Post-service records contain numerous treatment records. A recent January 2020 VA Problem List does not include any current or prior hand, arm, or leg disorders. The Veteran has not put forth any specific arguments for these claims. The Board acknowledges that he has not been afforded VA examinations with respect to his claims for service connection for bilateral hand, bilateral arm, and bilateral leg disabilities. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). A VA examination under the standards of McLendon is not warranted as there is simply no evidence establishing an “in-service event” during active service, and there is no evidence of an indication that any current disability or current symptoms may be related to any alleged in-service event. The Veteran has not offered any specific lay statements as to why he believes these claimed disabilities are a result of his period of service or medical evidence indicating a link between any current diagnosis and his time in service. After review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against finding that any post-service bilateral arm, bilateral hand, or bilateral leg disorder had an onset during service or is in any way causally or etiologically due to service. While the Veteran is competent to report experiencing symptoms, such as pain, he is not competent to provide a diagnosis or competently opine as to the etiology of these claimed disabilities. The issues are medically complex, as they require knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). There is simply no competent and probative evidence of record relating the Veteran’s claimed disabilities to his time in service or a service-connected disability. For the reasons stated above, the Board finds that the preponderance of evidence is against the claims of entitlement to service connection for a bilateral hand disability, bilateral arm disability and bilateral leg disability, and must be denied. There is no reasonable doubt to be resolved as to these issues. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 6. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD with anxiety and depression. The Veteran seeks entitlement to service connection for an acquired psychiatric disorder, to include PTSD with anxiety and depression. By way of history, as noted in the June 2019 Board remand, the Veteran has continuously appealed this claim since his original claim in March 2013 and denial in a February 2014 rating decision. There are particular requirements for establishing PTSD in 38 C.F.R. § 3.304 (f), which take precedence over the general requirements for establishing service connection in 38 C.F.R. § 3.303. See Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Establishment of service connection for PTSD requires: (1) medical evidence diagnosing PTSD; (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304 (f). After a careful review of the evidence of record, and resolving all doubt in favor of the Veteran, entitlement to service connection for PTSD with major depressive disorder and adjustment disorder is warranted. First, the Veteran has a current diagnosis of PTSD with major depressive disorder and adjustment disorder. See October 2013 VA examination; October 2017 Disability Benefits Questionnaire (DBQ). The Board therefore finds that the evidence demonstrates the Veteran has a current diagnosis, meeting the first requirement for the establishment of service connection. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). As for the second requirement, the Veteran has asserted multiple stressors, to include a personal assault during service. Claimed stressors must generally be verified, but VA has acknowledged that stressors related to personal assaults may be more difficult to corroborate than other claimed stressors. Accordingly, in such cases, stressors may be verified via alternate means, including through behavior changes, records from law enforcement authorities, and statements from fellow soldiers, family members, or friends. The Veteran reported that he was verbally and physically assaulted during service by six other servicemembers, who punched and kicked him. After the assault, the Veteran asserts he continued to be verbally abused during service. The Board notes that there is no specific documentation of the Veteran’s claimed assault while on active duty; however, several of the Veteran’s fellow servicemembers submitted statements corroborating the Veteran’s account. See, e.g., November 2018 statements from C.R., A.G., and A.H. The Board finds the Veteran’s descriptions of his in-service personal assault are both competent and credible. Additionally, the Board finds the additional lay statements of record from the Veteran’s three fellow servicemembers are credible. Accordingly, the Board finds that the totality of the evidence sufficiently corroborates the Veteran’s contentions of a personal trauma during service. As such, element (2) is met. Regarding the nexus element, the October 2013 VA examiner stated that the Veteran described marked interpersonal stress during service that included racial bullying, harassment and an altercation. The examiner stated that at the time the Veteran did not meet the criteria for a diagnosis of PTSD, but that his reports of verbal and emotional abuse during service was relevant to his current symptoms and behaviors, which were diagnosed as an adjustment disorder. Additionally, the October 2017 psychologist opined that the Veteran’s PTSD with major depressive disorder was at least as likely as not due to service. The psychologist explained that mental health treatment notes refer to unfair treatment and harassment during service, to include racism and bullying from superiors, which led to persistent feelings of anger, with resulting difficulty sustaining employment and impairment in relationships. Based on this evidence, the psychologist opined it was at least as likely as not that the Veteran’s PTSD was due to service, noting that the Veteran’s reported stressor of the in-service assault meets Criterion A to support the diagnosis of PTSD. Under the benefit of the doubt rule, where there exists “an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter,” the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-207 (1994). Given the evidence of record, the Board resolves doubt in the Veteran’s favor and finds that the evidence supports the establishment of service connection for an acquired psychiatric disorder, diagnosed as PTSD with major depressive disorder and adjustment disorder. The Veteran has a current diagnosis, a conceded in-service personal assault, and a medical opinion that relates his current diagnosis to his time in service. In light of the discussion above, while the evidence is not unequivocal, it has nonetheless placed the record in relative equipoise. As such, the Veteran’s claim is granted. REASONS FOR REMAND 7. Entitlement to service connection for bilateral pes planus, claimed as a bilateral foot disability. Importantly, the Veteran’s service treatment records are significant for findings of bilateral pes planus. Specifically, the Veteran’s April 1987 enlistment examination shows that he had moderate pes planus, asymptomatic, upon entry to service. Post-service treatment records indicate the Veteran continues to suffer from bilateral pes planus and an August 2019 VA treatment note reports a painful, depressed medial longitudinal arch with excessive foot pronation. The Veteran was noted to walk with an abducted gait with his heel everted during stance. On remand, the Veteran should be afforded a VA examination and a medical opinion should be obtained regarding whether the Veteran’s bilateral pes planus was aggravated during service. 8. Entitlement to service connection for sleep apnea, to include as secondary to service-connected acquired psychiatric disorder. The Veteran seeks entitlement to service connection for sleep apnea. He has a current diagnosis of obstructive sleep apnea. The Veteran submitted multiple statements from fellow servicemembers who reported he often stopped breathing during his sleep and snored loudly while in service. See, e.g., November 2018 statements from A.H., A.G., and C.R. The claim was remanded in June 2019 to obtain a medical opinion as to whether the Veteran’s sleep apnea had an onset during service or was secondary to his acquired psychiatric disorder. A VA medical opinion was obtained January 2020, at which time the examiner opined that the Veteran’s sleep apnea was less likely than not due to upper respiratory infections during service and less likely than not caused by or aggravated by his acquired psychiatric disorder. The examiner stated, “lay statement noted.” However, no further explanation was provided, and no opinion was offered regarding whether the Veteran’s sleep apnea had an onset during service. Furthermore, the Board notes that although several medical opinions have been obtained, they do not consider and discuss the lay statements provided by the Veteran’s fellow servicemember. In fact, several medical opinions indicate that although the Veteran reported a history of symptoms back to 1991, there was no such documentation of symptoms prior to 2012. The Board finds a remand is necessary to obtain a medical opinion regarding whether the Veteran’s sleep apnea had an onset during service. The opinion must consider and discuss the lay statements provided by the Veteran’s fellow servicemembers. 9. Entitlement to service connection for diabetes mellitus, type 2, to include as secondary to service-connected acquired psychiatric disorder. The Veteran seeks entitlement to service connection for diabetes mellitus, type 2. The Veteran has a current diagnosis of diabetes mellitus, type 2. As noted in the June 2019 Board remand, the Veteran’s service treatment records indicate that just prior to active service in March 1989 and August 1990 the Veteran had elevated glucose levels in his urine. The claim was remanded to obtain a VA medical opinion, and the examiner was directed to include comments and a discussion on the significance of the Veteran’s elevated glucose in urine noted prior to service. A VA medical opinion was obtained in December 2019. The examiner noted the Veteran’s elevated glucose in urine prior to service, and opined that it was less likely than not that the Veteran’s current diabetes was due to service since it predated service; however, the examiner then stated that diabetes is diagnosed with fasting sugar blood tests or A1c blood tests and none of these were completed during service. The examiner noted that the Veteran reported marijuana usage in April 1987 and marijuana can cause cannabis induced glucose intolerance. The Board finds this medical opinion is contradictory and confusing. First, the Veteran did not have a pre-existing diagnosis of diabetes noted upon entrance to service. Therefore, if the Board is to find that the presumption of soundness is rebutted and that the Veteran’s diabetes pre-existed service, it must find (1) that clear and unmistakable evidence shows that diabetes pre-existed service; and was not aggravated by service. Additionally, the examiner indicated the Veteran’s diabetes predated service, but then explained that diabetes is diagnosed with fasting sugar blood tests or A1c blood tests, which were not completed during service and opined that the Veteran’s marijuana use could have caused induced glucose intolerance. On remand, a medical opinion should be obtained as to whether the Veteran’s diabetes clearly and unmistakably pre-existed service, and if so, whether it was not aggravated during service. 10. Entitlement to service connection for hypertension, to include as secondary to diabetes mellitus, type 2, and/or service-connected acquired psychiatric disorder. 11. Entitlement to service connection for erectile dysfunction, to include as secondary to diabetes mellitus, type 2, and/or service-connected acquired psychiatric disorder. The Veteran also seeks entitlement to service connection for hypertension and erectile dysfunction, to include as secondary to diabetes mellitus, type 2, and/or his service-connected acquired psychiatric disorder. The Veteran has argued that his erectile dysfunction is due to medications taken for his acquired psychiatric disorder and/or diabetes. The Board finds that these issues are intertwined with the issue of entitlement to service connection for diabetes mellitus, type 2; therefore, a decision on these claims are being deferred pending completion of the development ordered. Additionally, the June 2019 remand requested a VA medical opinion regarding whether the Veteran’s erectile dysfunction was due to medications taken for his acquired psychiatric disorder and/or diabetes. Although a medical opinion was obtained in December 2019, the examiner did not provide any rationale for the negative opinion. On remand, an addendum should be obtained. 12. Entitlement to an initial rating higher than 10 percent for dermatitis. As noted in the June 2019 remand, the Veteran asserted that his skin disorder is more severe than what was reflected by the October 2015 VA examination. The Veteran submitted photographs of his skin during a flare-up in 2014 and testified that he did not understand why the VA examiner reported that only his hands and feet are affected when the dermatitis affects almost the entirety of his body. The October 2015 VA examiner noted the Veteran’s disability had improved since the photographs were taken but did not offer any discussion regarding the Veteran’s flare-ups. The examiner included a copy of a February 2015 VA treatment note in the examination report that indicates the Veteran’s bilateral feet, hands, fingers, back, shoulders, face and arms were affected at that time. The RO was directed to afford the Veteran a new VA examination. If the examination was not scheduled during a flare-up, the Veteran was to provide lay testimony to the examiner regarding the location and severity of his dermatitis that occurs during a period of active outbreak. The examiner was also instructed to describe the area(s) of the body affected by dermatitis, to include the percentage of the entire body affected and the percentage of exposed area(s) affected, OR (ii) estimate, if possible, the area(s) of the body affected by dermatitis, to include the percentage of the entire body affected and the percentage of exposed area(s) affected claimed by the Veteran in the event he was currently not experiencing a full active outbreak. The Veteran was afforded a VA examination in December 2019. The examiner stated that the Veteran did not currently have a skin condition and it had resolved. No further explanation was provided, and the examiner did not estimate the area(s) of the body affected, to include the percentage of the entire body affected during outbreaks. The Board notes that although the Veteran may not have currently had an outbreak during the December 2019 VA examination, or it may have resolved completely and the Veteran no longer has a current diagnosis, the Veteran did have outbreaks during the course of this appeal, as evidenced by a February 2015 VA treatment note and photographs from 2014. As such, this issue is remanded to obtain an addendum opinion regarding the severity of the Veteran’s skin disorder throughout the course of the appeal. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records. 2. Afford the Veteran a VA examination for bilateral pes planus. The claims file, including a copy of this remand, should be made available to and reviewed by the examiner. Upon review of the file and examination of the Veteran, the examiner is asked to respond to the following: (a.) Is it at least as likely as not (50 percent probability or greater) that there was an increase in severity of the pre-existing bilateral pes planus during service? (b.) If the examiner finds that there was an increase in severity during service, the examiner should further render an opinion as to whether any such increase was clearly and unmistakably (obvious and manifest) due to the natural progress of the disorder. The term “clear and unmistakable evidence” means that the evidence cannot be misinterpreted or misunderstood, i.e., the evidence is undebatable. (c.) In responding to this question, please acknowledge and discuss the medical and lay evidence as to the severity of his foot condition during and post service. This examiner should consider and discuss the diagnosis of asymptomatic, moderate bilateral pes planus at service entry and the post-service VA treatment record of August 2019 noting a painful, depressed medial longitudinal arch with excessive foot pronation and that the Veteran was noted to walk with an abducted gait with his heel everted during stance. The examiner must provide a complete rationale for any opinion expressed, based on the examiner’s clinical experience, medical expertise, and established medical principles. 3. Obtain an addendum opinion for the Veteran’s sleep apnea. The entire claims file should be made available to and reviewed by the examiner. No additional examination is necessary, unless the examiner determines otherwise. Following a review of the claims file, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed obstructive sleep apnea had its onset in or is otherwise related to service. *The examiner is asked to specifically consider the Veteran’s lay statements and the November 2018 statements from fellow servicemembers that symptoms of sleep apnea, such as snoring, catching his breath, and not breathing during sleep, began during active duty and were evidenced by fellow service-members. A complete rationale should be given for all opinions and conclusions expressed. 4. Obtain an addendum opinion for the Veteran’s diabetes mellitus, type 2. The entire claims file should be made available to and reviewed by the examiner. No additional examination is necessary, unless the examiner determines otherwise. a) Following a review of the claims file, the examiner should opine as to whether it is clear and unmistakable that the Veteran entered service with diabetes mellitus, type 2. b) If the Veteran’s diabetes mellitus, type 2, clearly and unmistakably pre-existed service, the examiner should determine whether it is clear and unmistakable that his diabetes WAS NOT aggravated beyond the natural progress of the disorder during his service. c) If the Veteran’s diabetes did not clearly and unmistakably pre-exist service, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., 50 percent or greater probability) that his diabetes had an onset during service or is causally or etiologically due to his service. d) The examiner should also opine whether it is at least as likely as not (i.e., 50 percent or greater probability) that the Veteran’s diabetes is proximately due to OR aggravated (beyond a natural progression) by his service-connected acquired psychiatric disorder. *In particular, the examiner should consider the March 1989 and August 1990 elevated glucose levels in his urine just prior to active service. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. Obtain an addendum opinion for the Veteran’s erectile dysfunction. Following a review of the claims file, the VA examiner should offer an opinion on the following: Is it at least as likely as not that the Veteran’s erectile dysfunction is proximately due to or aggravated (beyond a natural progression) by his acquired psychiatric disorder and/or diabetes mellitus, type 2, to include any medications currently prescribed for treatment of these disorders? All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. Obtain an addendum opinion to determine the severity of the Veteran’s dermatitis. The examiner should review the claims file. The examiner is asked to address the following: In light of the VA examination findings, the Veteran’s lay reports, the photographs submitted by the Veteran in 2014, and the findings contained in the February 2015 VA treatment record, the examiner should estimate, if possible, the area(s) of the body affected by dermatitis, to include the percentage of the entire body affected and the percentage of exposed area(s) affected claimed by the Veteran during periods of flare-ups that occurred throughout the course of this appeal. The examiner should also discuss the medications used to treat the condition to include the frequency of use and the duration of the treatment. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Andersen, 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.