Citation Nr: 21013535 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 13-00 682 DATE: March 9, 2021 ORDER Service connection for chronic kidney disease, including as due to exposure to contaminated water at Camp Lejeune, is granted. Service connection for anemia, to include as due to chronic kidney disease, is granted. REMANDED Entitlement to service connection for hypertension, to include as due to chronic kidney disease, is remanded. Entitlement to service connection for erectile dysfunction, to include as due to chronic kidney disease, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU), due exclusively to depression disorder, a disability manifested by insomnia, hypertension, and chronic kidney disease, is remanded. FINDINGS OF FACT 1. The competent evidence of record shows that the Veteran’s chronic kidney disease did not manifest until years after service, and the preponderance of the evidence is in favor of a finding of nexus between the chronic kidney disease and service. 2. The competent evidence of record shows that the Veteran’s anemia did not manifest until years after service, and the preponderance of the evidence is in favor of a finding that the anemia was proximately caused by the service-connected chronic kidney disease. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic kidney disease on a direct basis are met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for anemia, as secondary to the service-connected chronic kidney disease, are met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, served on active duty in the United States Marine Corps from March 1978 to March 1981. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2011 rating decision of a Department of Veterans’ Affairs (VA) Regional Office (RO). In March 2013, the Veteran testified during a hearing before a Veterans Law Judge (VLJ). Thereafter, the VLJ before whom the Veteran appeared retired from the Board. As such, the case was assigned to the undersigned VLJ and the Veteran was afforded a new hearing on the instant claims in January 2021. Copies of both hearing transcripts are of record and have been reviewed. In February 2015, the Board denied service connection for PTSD, an acquired psychiatric disorder other than PTSD, and insomnia, and remanded for further development the service connection claims for erectile dysfunction, chronic kidney disease, hypertension, and anemia, as well as the Veteran’s claim for entitlement to a TDIU, to include affording the Veteran VA examinations and obtaining VA medical opinions. The claims for service connection for hypertension and erectile dysfunction are remanded because there has not been substantial compliance with the Board’s February 2015 remand directives in regard to either claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). As phrased on the title page herein, the Board has recharacterized the issue of entitlement to service connection for erectile dysfunction to include “as due to chronic kidney disease” to better reflect the information contained in the record, particularly testimony during the January 2021 Board hearing. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that the scope of a claim is determined by the claimant’s description of the claim, the symptoms described, and the information submitted or developed in support of the claim). Service Connection Applicable Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of 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). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b); Allen v. Brown, 8 Vet. App. 374 (1995). An alternative means of establishing service connection is showing continuity of symptomatology under 38 C.F.R. § 3.303(b), which is available for certain “chronic disease” specifically enumerated under 38 C.F.R. § 3.309(a). While the Veteran’s service connection claims include anemia, which is among the diseases enumerated under 38 C.F.R. § 3.309(a), the evidence does not reflect a diagnosis of this disorder until many years after his separation from service. Additionally, chronic kidney disease is not among the disorders enumerated under 38 C.F.R. § 3.309(a). Therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) are not for application. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The appellant bears the burden of presenting and supporting his or her claim for benefits. See 38 U.S.C. § 5107(a). Chronic Kidney Disease The Veteran asserts that his chronic kidney disease is related to service, specifically his exposure to contaminated water at Marine Corps Base Camp Lejeune in North Carolina (Camp Lejeune). At the outset, the Board finds that credible medical evidence establishes a current diagnosis of chronic kidney disease, specifically membranous glomerulonephritis. See VA nephrology consultation dated May 11, 2017; VA kidney transplant consultation dated October 22, 2020. Service connection for a disease associated with exposure to contaminated water at Camp Lejeune may be established on a presumptive basis if the evidences shows the following: (1) that the veteran served at Camp Lejeune for no less than 30 days (either consecutive or nonconsecutive) from August 1, 1953 to December 31, 1987; (2) that the veteran suffered from a disease associated with exposure to contaminants in the water supply at Camp Lejeune enumerated under 38 C.F.R. § 3.309(f); and (3) that the disease process manifested to a degree of 10 percent or more at any time after service. 38 C.F.R. §§ 3.307(a)(7), 3.309(f). Here, the record reflects that the Veteran was assigned to Camp Lejeune from January 1980 to February 1981, a period of approximately 13 months. However, the evidence does not reflect that the Veteran has been diagnosed with any of the diseases enumerated under 38 C.F.R. § 3.309(f). Therefore, the presumptive service connection provisions are not for application. Nevertheless, the Veteran is not precluded from establishing service connection for chronic kidney disease through proof of direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). VA has conceded that the Veteran was exposed to contaminated water at Camp Lejeune. See Rating Decision dated July 28, 2011 at g. 9. Copies of the Veteran’s service treatment records (STRs) are remarkably poor. The January 1978 enlistment examination appears to reflect a normal clinical evaluation and the Veteran denied any medical history related to kidney problems. The January 1981 separation examination appears to reflect a normal examination. The STRs that are legible do not appear to reflect symptoms, treatment, or diagnosis of kidney disease. Post-service treatment records reflect that the Veteran was diagnosed with membranous glomerulonephritis in 2009. In November 2019, the Veteran successfully underwent a kidney transplant. In June 2010, the Veteran was afforded a VA urology examination, during which the diagnosis of membranous glomerulonephritis was confirmed. The VA examiner also reviewed the Veteran’s claims file. However, the examiner noted that he was unable to opine as to whether the Veteran’s chronic kidney disease is related to exposure to contaminated water at Camp Lejeune without resort to speculation. See VA urology examination report dated June 18, 2010. In an addendum, the same VA examiner merely noted that in up to 85 percent of membranous glomerulonephritis cases, “the disease is idiopathic (unknown).” See VA addendum dated July 18, 2010. Between the two statements, the examiner provided no opinion addressing the etiology of the Veteran’s kidney disease. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). Accordingly, the Board assigns the June 2010 and July 2010 statements no probative value. Miller, supra. A July 2011 medical opinion by VA physician G.D., M.D., Chief of the Renal Section at the VA Medical Center Houston, reflects that he reviewed the Veteran’s medical records and performed literature review regarding whether the Veteran’s membranous glomerulonephritis was caused by exposure to solvents during service. Referencing several studies and the Veteran’s normal kidney function shown in 1994 treatment records, G.D. observed that there were no data or case reports indicating renal disease or membranous glomerulonephritis onset more than 13 years after exposure to solvents such as those found in water at Camp Lejeune. Notably, G.D. stated that the November 2009 renal biopsy report suggested the possibility of a secondary cause of membranous glomerulonephritis “besides solvent exposure between 1979 and 1981,” specifically, the Veteran’s “drug use (cocaine levels documented in medical record at Houston VAMC 2009 and 1994) can also be a risk factor for glomerulonephritis but not typically membranous glomerulonephritis.” See Correspondence dated July 5, 2011 from VA physician G.D., M.D. at pg. 2. Lastly, G.D. concluded: “There is no evidence that any of the chemical compounds found in the Camp Lejeune water cause membranous glomerulonephritis. In addition, there is no evidence that any of these chemicals would cause renal damage of any kind more than 13 years after exposure. Based on these data, membranous glomerulonephritis is not caused by or as a result of the Veteran’s exposure to contaminated water at Camp Lejeune.” Id. While referencing multiple studies in his opinion, G.D. failed to identify even one that suggests an inverse relationship between exposure to contaminants and the risk of developing kidney disease over time. Moreover, the examiner provided no correlation between the research and the Veteran’s exposure to contaminated water at Camp Lejeune or whether the Veteran’s kidney disease manifested in the usual manner that might make it as least as likely as not that his specific disease was directly related to such exposure. See Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (“an adequate medical report must rest on correct facts and reasoned medical judgment so as inform the Board on a medical question and facilitate the Board’s consideration and weighing of the report against any contrary reports.”). Additionally, G.D. failed to explain why greater weight was assigned to the risk presented by the Veteran’s cocaine use than to his exposure to contaminated water at Camp Lejeune as the cause of his membranous glomerulonephritis. See Nieves-Rodriguez, supra. Critically, the July 2011 VA opinion is internally inconsistent. On the one hand, G.D. stated that the 2009 renal biopsy suggested that “solvent exposure between 1979 and 1981” (when the Veteran was assigned to Camp Lejeune) was a possible cause of the Veteran’s kidney disease, but then concluded that there is no evidence that the Veteran’s disease was caused by his exposure to contaminated water at the facility. See Correspondence dated July 5, 2011 from VA physician G.D., M.D. at pg. 2. The examiner left this inconsistency unexplained. See Bloom, 12 Vet. App. at 187 (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion.”). Due to these deficiencies, the Board finds the July 2011 VA medical opinion of low to no probative value. Nieves-Rodriguez, supra. During the March 2013 Board hearing, the Veteran confirmed he was stationed at Camp Lejeune and was exposed to the camp water supply. The Board’s February 2015 remand requested a VA medical opinion to address the etiology of the Veteran’s kidney disease, considering a January 2014 VA surgery report for peritoneal dialysis and September 2014 laboratory results. The Board observes that the February 2017 VA opinion obtained pursuant ot the Board’s request does not reference this medical evidence. See Stegall, supra. Additionally, the medical opinion is dated eight days prior to the Veteran undergoing a VA kidney conditions examination. Noting that the Veteran was “potentially exposed” to low levels of solvents in Camp Lejeune water, and citing numerous studies regarding risk factors and exposures, the February 2017 VA examiner emphasized that there is insufficient medical evidence to conclude that there is an association between mixed solvent exposure and chronic glomerulonephritis. The examiner then concluded that because the Veteran’s renal function was normal in 1994 and the first indication of renal disease was not shown until 2009, 28 years after exposure, it was more likely that his kidney disease was caused by hypertension, hyperlipidemia, cocaine abuse, smoking, and/or alcohol dependence. See VA medical opinion dated February 19, 2017. However, the examiner cited no studies or research indicating an inverse relationship between exposure to contaminants and the risk of developing kidney disease over time. Additionally, the examiner failed to explain why greater weight was assigned to risk factors hypertension, hyperlipidemia, cocaine abuse, smoking, and alcohol dependence than to exposure to contaminated water at Camp Lejeune as the cause of the Veteran’s membranous glomerulonephritis. See Nieves-Rodriguez, supra. The Board recognizes that a medical professional’s opinion cannot be rejected simply because the opinion is based in part on statistical analysis. Rather, as discussed above, it is the total analysis provided by the medical professional that must be weighed and considered by the Board. See Nieves-Rodriguez, supra. In this regard, while the February 2017 VA examiner devoted considerable attention to the merits of the cited research, the examiner provided no correlation between the research and the Veteran’s exposure to contaminated water at Camp Lejeune or whether the Veteran’s kidney disease manifested in the usual manner that might make it as least as likely as not that his specific disease was directly related to such exposure. See Acevedo, supra. Due to these deficiencies, the Board finds the February 2017 VA medical opinion of low to no probative value. See Acevedo, supra, Nieves-Rodriguez, supra. An April 2019 medical opinion by private nurse practitioner is favorable. See Correspondence dated April 30, 2019 from A.C., N.P. However, because the opinion does not specify which of the Veteran’s disorders is related to exposure to contaminated water at Camp Lejeune. As a result, the opinion is speculative and of no probative value. See Obert v. Brown, 5 Vet. App. at 30, 33 (1993). The record includes a May 2019 medical opinion penned by the Veteran’s treating VA physician A.J., M.D., who notes that he has treated the Veteran through the renal clinic at a VA medical center since 2018. Doctor A.J. confirmed the Veteran’s diagnosis of membranous glomerulonephritis and stated that the Veteran was awaiting a kidney transplant at that time. He indicated that he reviewed the Veteran’s medical records as they pertain to his kidney disease and treatment. See Correspondence dated May 10, 2019 from A.J, M.D. A.J. acknowledged the Veteran’s exposure to contaminated water at Camp Lejeune and noted the review of literature associating such exposure with membranous glomerulonephritis. A.J. opined that the Veteran’s “Camp Lejeune toxic exposure … is the most probable etiology of his kidney disease[.]” Id. The private medical opinion of A.J. is competent, credible and probative; it was authored by a Board-certified nephrologist in a VA medical center renal care department, and he reviewed relevant treatment records. Although A.J. did not mention reviewing the Veteran’s STRs, it is unlikely review of such evidence by any of the opinion authors would have been productive considering their poor quality. The opinion contains a clear conclusion with a reasoned medical explanation. See Nieves-Rodriguez, supra. The nephrologist specifically opined that the Veteran’s membranous glomerulonephritis is most probably related to his in-service exposure to contaminated water at Camp Lejeune. In forming this opinion, the nephrologist considered the Veteran’s lay assertions of exposure as well as the Veteran’s ongoing symptoms. While A.J.’s opinion does not discuss the literature he stated reflects an association between membranous glomerulonephritis and exposure to contaminated water at Camp Lejeune, in this instance the Board finds that this shortcoming does not weigh against the probative worth of the opinion, considering that the VA examiners cited no specific literature to support their respective opinions that the Veteran’s kidney disease is not related to the exposure based on the passage of time between exposure and diagnosis of the disease. Further, although the U.S. Court of Appeals for Veterans Claims has not fully embraced a “treating physician rule” under which a treating physician’s opinion would presumptively be given greater weight than that of any other examiner, a medical professional’s opportunity or opportunities to examine a claimant over time may be considered in assigning probative weight. See Winsett v. West, 11 Vet. App. 420, 424-25 (1998). Thus, the Board finds the medical opinion of Doctor A.J. to be highly probative, competent and persuasive medical evidence in this case. Notably, there is no probative medical evidence of record that weighs against A.J.’s opinion. During the January 2021 Board hearing, the Veteran stated that he was stationed at Camp Lejeune from 1980 to 1981 and again asserted his contention that his kidney disease was caused by his exposure to the camp water supply. In view of the foregoing competent lay and medical evidence, the Board concludes that the preponderance of the evidence supports the Veteran’s claim for service connection for chronic kidney disease, as due to exposure to contaminated water at Camp Lejeune. The claim is therefore granted. The grant of service connection on a direct basis pursuant to 38 C.F.R. § 3.303 renders moot all other theories of service connection. Anemia The Veteran asserts that his anemia is related to service, to include as due to his service-connected chronic kidney disease. At the outset, the Board finds that credible medical evidence establishes a current diagnosis of anemia. See VA nephrology consultation dated December 19, 2018. As noted above, copies of the Veteran’s STRs are of poor quality. The January 1978 enlistment examination appears to reflect a normal clinical evaluation and the Veteran denied any medical history related health problems. The January 1981 separation examination appears to have been normal. The STRs that are legible do not appear to reflect symptoms, treatment, or diagnosis of anemia. Post-service treatment records reflect that the Veteran was diagnosed with anemia in 2009. See VA primary care initial evaluation dated June 15, 2009. During the January 2021 Board hearing, the Veteran stated that he believed his anemia symptoms began in approximately 2008. A February 2017 VA examiner opined that it is less likely than not that the Veteran’s anemia is related to active service because an April 30, 2010 VA hematology clinic note mentioned that the “renal insufficiency is the likely cause of anemia” and there is no documentation of anemia while in military service. Curiously, the VA examiner concluded that the Veteran’s anemia “has now resolved and the Veteran no longer has any anemia.” See VA medical opinion dated February 27, 2017. While the February 2017 VA examiner’s conclusion that the Veteran no longer has anemia is inconsistent with the examiner’s diagnosis of anemia in the associated February 2017 examination report, and therefore renders the opinion of questionable probative worth, the April 30, 2010 VA hematology consultation note itself supports the Veteran’s claim. To the extent that the consultation note represents a medical opinion, the Board observes that the VA physician identified the Veteran’s diagnosis, referenced extensive laboratory and diagnostic data regarding the Veteran’s kidney functions and blood condition, and considered the Veteran’s description of his anemia symptoms, namely increased fatigue. Notably, the VA physician’s opinion that the Veteran’s anemia is likely caused by renal insufficiency is consistent with medical literature, which shows that anemia is a common complication of chronic kidney disease. See Nat’l Inst. of Health, Inst. of Diabetes and Digestive & Kidney Diseases, https://www.niddk.nih.gov/health-information/kidney-disease/anemia (last reviewed Feb. 25, 2021). Indeed, the VA physician’s opinion is competent, credible and probative; it was authored by a Board-certified doctor identified as an attending physician in hematology, he reviewed relevant treatment and diagnostic data regarding the Veteran’s kidney functions and blood condition, and it contains a clear conclusion. See Nieves-Rodriguez, supra. Furthermore, the May 2019 correspondence from the Veteran’s treating physician, A.J., M.D., notes that anemia is a condition related to the Veteran’s chronic kidney disease. See Correspondence dated May 10, 2019 from A.J, M.D. Notably, there is no probative medical evidence of record that weighs against the VA physician’s April 2010 opinion or A.J. M.D.’s May 2019 finding. In view of the foregoing competent lay and medical evidence, the Board concludes that the preponderance of the evidence supports the Veteran’s claim for service connection for anemia. The claim is therefore granted. The grant of service connection on a direct basis pursuant to 38 C.F.R. § 3.303 renders moot all other theories of service connection. REASONS FOR REMAND Although the Board regrets the additional delay, remand is again necessary to ensure that due process is followed and there is a complete record upon which to decide the Veteran’s claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38C.F.R. § 3.159(c) (2020). Once VA undertakes the effort to provide an examination or medical opinion when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Additionally, the Board’s February 2015 remand requesting etiology opinions confers on the claimant, as a matter of law, the right to compliance with the remand order. See Stegall, supra. Hypertension In February 2017, a VA examiner opined that the Veteran’s hypertension is not directly related to service or to the Veteran’s chronic kidney disease because “prior rating decisions dated July 28, 2011 and August 6, 2014 verified that the current high blood pressure was not related to military service. There [are] no new documents that would refute that decision.” First, the VA examiner was expected to make an independent assessment of the etiology of the Veteran’s hypertension. See Acevedo, supra. Instead, the examiner concluded that there is no basis for direct or secondary service connection based on the RO’s July 2011 adjudication of the claim, a determination that is presently in question as it is the basis for this pending appeal. Second, there is no rating decision of record dated August 6, 2014, which is suggestive that the February 2017 VA examiner’s review of the claims file was cursory at best, rendering the opinion of little or no probative value. See Nieves-Rodriguez, supra. The remainder of the opinion merely references findings in treatment records with no independent analysis of their significance or meaning, or how they relate to the etiology of the Veteran’s hypertension. Id. For these reasons, the February 2017 VA medical opinion is inadequate. See Barr, supra. Accordingly, on remand, a medical opinion addressing the etiology of the Veteran’s hypertension must be obtained. Id. Erectile Dysfunction The February 2017 VA examiner opined that the Veteran’s erectile dysfunction is less likely than not related to active service, explaining that the Veteran did not have erectile dysfunction while in service, and that the Veteran’s “strong history of cocaine and alcohol abuse” would in itself result in erectile dysfunction. The absence of evidence in the Veteran’s service treatment records, alone, may not serve as the basis for a negative opinion as to direct service connection. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). Additionally, the examiner failed to explain why significant weight was assigned to the Veteran’s history of cocaine and alcohol use as the cause of erectile dysfunction to the exclusion of other possible etiologies. See Nieves-Rodriguez, supra. Accordingly, on remand, a medical opinion addressing the etiology of the Veteran’s erectile dysfunction must be obtained. See Barr, supra. TDIU The record as presently developed does not include sufficient evidence upon which to adjudicate the Veteran’s TDIU claim. Namely, the service connection claims for hypertension and erectile dysfunction have yet to be fully adjudicated, and no disability evaluations have been assigned to the now service-connected chronic kidney disease or anemia, granted herein, since the Board does not assign disability ratings or effective dates in the first instance. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of “downstream” elements such as the disability rating or effective date assigned). Therefore, the issue of entitlement to a TDIU is remanded as intertwined with the pending service connection claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). The matters are REMANDED for the following action: 1. Implement the Board’s decision herein granting service connection for chronic kidney disease and anemia. 2. Ensure that all outstanding VA treatment records are associated with the claims file. 3. Then, request an addendum opinion from an appropriately qualified VA examiner other than the author of the February 2017 VA opinions, as to the nature and etiology of the Veteran’s hypertension. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. If an examination(s) is performed, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail and correlated to a specific diagnosis. After a complete review of the claims file, the examiner is asked to provide an opinion with complete rationale addressing the following: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s currently diagnosed hypertension was CAUSED or AGGRAVATED by the service- chronic kidney disease. *Any increase/aggravation is sufficient, permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). (b) If the answer to (a) is negative, provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed hypertension onset during active duty service, manifested within one year after service separation, or is otherwise casually or etiologically related to it. The examiner should provide a complete rationale for each opinion. 4. Request an addendum opinion from an appropriately qualified VA examiner other than the author of the February 2017 VA opinions, as to the nature and etiology of the Veteran’s erectile dysfunction. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. If an examination(s) is performed, all indicated studies, tests, and evaluations must be conducted, and all findings reported in detail and correlated to a specific diagnosis. After a complete review of the claims file, the examiner is asked to provide an opinion with complete rationale addressing the following: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s currently diagnosed erectile dysfunction was CAUSED or AGGRAVATED by the service- chronic kidney disease. *Any increase/aggravation is sufficient, permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). (b) If the answer to (a) is negative, provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed erectile dysfunction onset during active duty service, manifested within one year after service separation, or is otherwise casually or etiologically related to it. Although the examiner must review the entire claims file, the examiner is requested to consider the following potentially relevant evidence, which is identified by VBMS label and receipt date in parenthesis. 2014 World Journal of Nephrology article entitled “Chronic kidney disease and erectile dysfunction” (see VBMS entry with document type “Correspondence,” receipt date 01/08/2021). *The Board’s reference to evidence in this context should not be construed as a determination of its credibility. The examiner should provide a complete rationale for each opinion. 5. Thereafter, ensure that the examiner(s) has substantially responded to the questions posed by the Board, and if not, take corrective action. 6. Then, readjudicate the remanded claims, including the intertwined TDIU claim. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Farrell 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.