Citation Nr: 21013876 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 14-13 941 DATE: March 10, 2021 ORDER Entitlement to service connection for major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified (claimed also as posttraumatic stress disorder (PTSD)) is granted. Entitlement to service connection for back disability is denied. Entitlement to service connection for bilateral neurological disability of the lower extremities is denied. REMANDED Entitlement to service connection for bilateral eye disability is remanded. Entitlement to service connection for sleep disability is remanded. Entitlement to service connection for bilateral knee disability is remanded. Entitlement to service connection for left hip disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran’s current major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified began during active service. 2. The Veteran’s back disability did not have its onset in service, did not manifest to a compensable degree within the first post-service year, and is not otherwise related to an in-service injury or disease. 3. The Veteran’s bilateral neurological disability of the lower extremities did not have its onset in service, did not manifest to a compensable degree within the first post-service year, and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified are met. 38 U.S.C. §§ 1110, 1111, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for back disability are not met. 38 U.S.C. §§ 1101 (3), 1110, 1111, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for bilateral neurological disability of the lower extremities are not met. 38 U.S.C. §§ 1101 (3), 1110, 1111, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1966 to January 1968, which includes service in the Republic of Vietnam. These matters initially came before the Board of Veterans’ Appeals (Board) from May 2011, February 2015, and June 2015 rating decisions. In April 2016, the Board remanded these matters for further development. In February 2018, the Board granted the Veteran’s applications to reopen claims of service connection for PTSD, psychiatric disability other than PTSD, back disability, and bilateral neurological disability of the lower extremities. The Board denied the underlying claims of service connection for PTSD, psychiatric disability other than PTSD, bilateral eye disability (characterized as glaucoma), and a sleep disability. Also, the Board remanded the other matters on appeal for further development. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In December 2018, the Court set aside the Board’s February 2018 decision, in part, and remanded to the Board the issues of entitlement to service connection for PTSD, psychiatric disability other than PTSD, bilateral eye disability, and sleep disability for readjudication in compliance with directives specified in an October 2018 Joint Motion filed by counsel for the Veteran and VA. In June 2019, the Board remanded the issues of entitlement to service connection for PTSD, psychiatric disability other than PTSD, bilateral eye disability, and sleep disability for further development. In October 2019, the Board remanded the issues of entitlement to service connection for back disability, bilateral knee disability, bilateral neurological disability of the lower extremities, and left hip disability and entitlement to a TDIU for further development. As for characterization of the issues on appeal, in light of the Veteran’s reported symptoms and contentions, and to encompass all disorders that are reasonably raised by the record, the Board has re-characterized the claim of service connection for glaucoma as a claim of service connection for bilateral eye disability. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that, in determining the scope of a claim, the Board must consider the claimant’s description of the claim, the symptoms described, and the information submitted or developed in support of the claim). Moreover, the Board points out that the issue of entitlement to service connection for tinnitus was also remanded in June 2019 for further development. A supplemental statement of the case (SSOC) that included the tinnitus matter was subsequently issued in December 2019. Thereafter, the Veteran opted-in to the Appeals Modernization Act (AMA) review system by submitting a timely “Decision Review Request: Supplemental Claim” form (VA Form 20-0995) in January 2020, on which he identified the issues of entitlement to service connection for tinnitus and psychiatric disability. Therefore, the issue of entitlement to service connection for tinnitus will be addressed separately by the agency of original jurisdiction (AOJ) in a future correspondence. The Board notes, however, that the issue of entitlement to service connection for PTSD remains on appeal before the Board in the legacy appeal system. Although the Veteran opted-in to the AMA review system with respect to the issue of entitlement to service connection for psychiatric disability other than PTSD, a claim of service connection for PTSD encompasses a claim of service connection for any psychiatric disability no matter how it is diagnosed. See Clemons, 23 Vet. App. at 1. As explained in more detail below, the Board is awarding service connection for major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified (claimed also as PTSD). As a final preliminary matter, in the April 2016, February 2018, and October 2019 remands, the Board instructed the AOJ to, among other things, ask the Veteran to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records (to include records from Dr. Walters-O’Neill; Dr. Cubano; Farmacia Dorado; Emerson PR, Inc.; Dr. Dedeyil; Vega Alta Radiology; Dr. Munoz; Dr. Reyes; Ravia Hospital Hato Rey; Dr. Quesada; and Dr. Rodriguez), obtain all outstanding VA treatment records, obtain the Veteran’s relevant Social Security Administration (SSA) records, afford the Veteran VA examinations to assess the nature of his claimed back and lower extremity neurological disabilities, and obtain medical opinions as to whether any such disabilities are related to service. Pursuant to the Board’s remands, the AOJ contacted the SSA and requested the Veteran’s relevant outstanding records. The SSA responded in June 2016 that the Veteran’s SSA records did not exist and that further efforts to obtain them would be futile because his records had been destroyed. In a June 2016 letter, the AOJ informed the Veteran that his SSA records were not available, notified him of the efforts that were undertaken to obtain the records, and asked him to submit any SSA records that were in his possession. Moreover, the Veteran was asked to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records (to include records from Dr. Walters-O’Neill; Dr. Cubano; Farmacia Dorado; Emerson PR, Inc.; Dr. Dedeyil; Vega Alta Radiology; Dr. Munoz; Dr. Reyes; Ravia Hospital Hato Rey; Dr. Quesada; and Dr. Rodriguez) by way of letters dated in June 2016 and November 2019. Copies of the authorization forms (VA Forms 21-4142a and 21-4142) were included with the letters. Also, all identified outstanding VA treatment records and private medical records were obtained and associated with the claims file, the Veteran was afforded VA back and neurological examinations in March 2019, and medical opinions were most recently provided in January 2020 as to whether the Veteran’s claimed back disability and bilateral neurological disability of the lower extremities are related to service. As explained in more detail below, the Board finds the January 2020 opinions to be adequate and of substantial probative value. Therefore, the AOJ substantially complied with the Board’s pertinent remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran, who, during active military service, served in the Republic of Vietnam during the period beginning in January 1962 and ending in May 1975, is presumed to have been exposed to herbicide agents, including Agent Orange. 38 U.S.C. § 1116 (f); 38 C.F.R. § 3.307 (a)(6)(iii). Service “in the Republic of Vietnam” includes service both on the landmass of Vietnam and the waters that are no more than 12 miles offshore of Vietnam. 38 U.S.C. § 1116A (a). If a veteran was exposed to an herbicide agent (to include Agent Orange) during active military, naval, or air service, the following diseases shall be service-connected if the requirements of 38 C.F.R. § 3.307 (a)(6) are met, even if there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 (d) are also satisfied: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; Type 2 diabetes; Hodgkin’s disease; ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina); all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin’s lymphoma; Parkinson’s disease; early-onset peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi’s sarcoma, or mesothelioma); parkinsonism; bladder cancer; and hypothyroidism. 38 U.S.C. § 1116(a)(2); 38 C.F.R. § 3.309 (e). “Early onset” peripheral neuropathy is defined as peripheral neuropathy that becomes manifest to a degree of 10 percent or more within one year after the Veteran’s last in-service exposure to herbicide agents (August 1967 in this case). 38 C.F.R. § 3.307 (a)(6)(ii). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a) (e.g., organic diseases of the nervous system and arthritis). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). Although entitlement to service connection on any of the presumptive bases noted above may not be established, a claimant is not precluded from establishing service connection on a direct basis. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). 1. Entitlement to service connection for major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified (claimed also as PTSD) The Veteran contends that he has current psychiatric disability which had its onset in service. The Board finds, for the following reasons, that the Veteran experiences current major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified, and that the evidence is at least evenly balanced as to whether these disabilities began during active service. As an initial matter, the Board notes that the Veteran reported on a September 1965 report of medical history form completed for purposes of entrance into service that he experienced a history of nervous disorders. The Board points out, however, that a veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). The term “noted,” in 38 U.S.C. § 1111, refers to “[o]nly such conditions as are recorded in examination reports.” 38 C.F.R. § 3.304 (b). A “[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions.” 38 C.F.R. § 3.304 (b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994). In this case, although the Veteran is competent to report a history of psychiatric problems prior to service, a veteran’s report of history, even when related by a medical professional, without an independent basis in the record, is insufficient to rebut the presumption of soundness. Miller v. West, 11 Vet. App. 345 (1998). There is no other evidence of any pre-existing psychiatric disability prior to service and the Veteran’s September 1965 entrance examination did not reflect any psychiatric abnormalities. Therefore, the Board finds that the evidence is not clear and unmistakable that any psychiatric disability pre-existed service and was not aggravated in service and the Veteran is presumed sound at service entrance. 38 U.S.C. § 1111. Medical records, including a September 2010 VA mental health treatment plan note and the reports of VA psychiatric examinations dated in October 2015 and July 2019, show that the Veteran experiences current major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified. Therefore, current psychiatric disability has been demonstration. There is also evidence of psychiatric symptoms in service and evidence of continuous symptoms in the years since service. In this regard, the Veteran has reported that he began to experience nervousness in service. For instance, he reported on a May 1968 “Veteran’s Application for Compensation or Pension” form (VA Form 21-526) that he experienced a nervous condition during service. Also, a note dated in 1971 from C.A. Walters-O’Neill, M.D., M.P.H. indicates that the Veteran was very nervous and that he reported that “when he was discharged from service he was in a terrible nervous condition.” The Veteran’s service personnel records reflect that he served in Vietnam from August 1966 to August 1967. Also, he reported during the October 2015 VA psychiatric examination that his compound in Vietnam was hit by numerous enemy attacks. A determination that a veteran engaged in combat with the enemy may be supported by any evidence which is probative of that fact, and there is no specific limitation of the type or form of evidence that may be used to support such a finding. See VAOPGCPREC 12-99 (October 18, 1999) (combat determination should be made on a case by case basis where there is no medal specifically indicating combat service). Evidence submitted to support a claim that a veteran engaged in combat may include the veteran’s own statements and an “almost unlimited” variety of other types of evidence. Gaines v. West, 11 Vet. App. 353, 359 (1998). Receiving enemy fire or firing on an enemy can constitute participation in combat. Sizemore v. Principi, 18 Vet. App. 264 (2004). The Veteran is competent to report his exposure to incoming enemy fire in service and there is no evidence that explicitly contradicts his reports. Therefore, the Board finds that his reports of combat exposure in service are credible and that there is sufficient evidence that the Veteran participated in combat/was exposed to incoming enemy fire while serving in Vietnam. Where a veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships of service. 38 U.S.C. § 1154 (b). The combat rules not only reduce the evidentiary burden for establishing in-service injury but allow a combat veteran to use “satisfactory lay or other evidence” to establish that he incurred the disability itself in service, even in cases where “there is no official record” that such injury or disability occurred. Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012). The Veteran’s reports of psychiatric problems in combat situations in service are satisfactory evidence and the reports are consistent with the circumstances of his service in Vietnam. There is no clear and convincing evidence to the contrary. Therefore, the presence of psychiatric symptoms in service is established. Moreover, the Veteran initially submitted a claim of service connection for psychiatric disability in May 1968 (only months after his separation from service in January 1968) and his post-service medical records and lay statements indicate that his psychiatric symptoms have continued in the years since service (see e.g., a December 2010 VA psychiatric examination report, which reveals that the Veteran reported that he had been “hearing voices calling his name at times since military service”). The Veteran is competent to report continuous psychiatric symptoms in the years since service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). There is nothing to explicitly contradict his reports and they are generally consistent with the evidence of record. Thus, the Board finds that the reports of continuous psychiatric symptoms in the years since service are credible. The psychiatrist who conducted a November 2014 VA psychiatric examination opined that the Veteran’s claimed psychiatric disability was not likely (“less likely than not”/“less than 50 percent probability”) incurred in or caused by service. He reasoned that the Veteran’s major depression had no temporal relationship with military stressors and that he sought formal psychiatric treatment in 2002 (34 years after his discharge from service). The examiner who conducted the October 2015 VA psychiatric examination opined that the Veteran’s psychiatric disability was not likely (“less likely than not”/“less than 50 percent probability”) incurred in or caused by service. The examiner reasoned that the Veteran’s cognitive disorder was not all related to his military service in terms of anatomy, pathophysiology, or etiology. His first encounter with a mental health professional was in August 1995, which was 27 years after his discharge from service and the events that led to his military stressors. A temporal relationship between his neuropsychiatric disorder and service was not established. The examiner who conducted a July 2016 VA psychiatric examination opined that the Veteran’s major depressive disorder was not due to, related to, incurred in, or associated in any way with service. The examiner explained, in pertinent part, that there was no evidence of any psychiatric complaints, findings, or treatment during service or within one year of his separation from service. The Veteran sought formal psychiatric treatment around 1999, which was almost 31 years after service. There was no relationship between the Veteran’s service and the psychiatric condition found in 1999. A temporal relationship between the Veteran’s neuropsychiatric disorder and service was not established and major depressive disorder had no relationship to service. The psychiatrist who conducted the July 2019 VA psychiatric examination opined that the Veteran’s major depressive disorder was not due to, related, incurred in, or in any way associated to service. There was no relationship between his service and the psychiatric condition found in 1999. Also, a temporal relationship between his neuropsychiatric disorder and service was not established. The examiner explained that there was no evidence of any psychiatric complaints, diagnosis, or treatment during service and that the Veteran’s records showed that his initial psychiatric complaints and treatment were in 1999, 30 years after service. The April 2014, October 2015, July 2016, and July 2019 opinions are all of little, if any, probative value because they are based upon an inaccurate history. Specifically, the examiners reasoned that there was no evidence of any psychiatric problems for decades following service, and that the Veteran did not seek treatment for psychiatric problems until 1995 at the earliest. However, as explained above, the 1971 statement from Dr. Walters-O’Neill indicates that the Veteran sought treatment for nervousness at that time. Therefore, the April 2014, October 2015, July 2016, and July 2019 opinions are based on an inaccurate history and are of little probative value. Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (“If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely”). Moreover, the opinions are all partially based on the absence of clinical evidence of treatment for psychiatric problems in service, and they do not take into account the competent and credible lay reports of psychiatric symptoms in service and continuous symptoms in the years since service. In this regard, a medical opinion is inadequate if it is based solely on the absence of documentation in the record and does not take into account the Veteran’s reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). This is particularly true in the case of a combat veteran. Congress enacted the combat statute because of its concern that combat veterans faced “major obstacle[s]” when seeking to assemble the medical records necessary to establish that they suffered an injury or disease while in service. Reeves, 682 F.3d at 998 (citing H.R. Rep. No. 1157, at 3 (1941)). In many instances, medical records do not survive combat conditions. Id. Moreover, due to the exigencies of battle, soldiers may not immediately seek medical treatment for combat-related injuries. Id. Thus, to the extent that the November 2014, October 2015, July 2016, and July 2019 opinions were based on a lack of report of psychiatric problems during service, this is precisely the reasoning that the combat law was designed to prevent. In sum, the evidence reflects that the Veteran experienced psychiatric symptoms in service and that there have been continuous symptoms in the years since service. He also experiences current major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified. There is no adequate medical opinion contrary to a conclusion that the current major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified had their onset in service. Thus, the evidence is at least evenly balanced as to whether these disabilities had their onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. See also Buchanan, 451 F.3d at 1335 (“[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself”). The Board notes that the benefit granted herein is service connection for major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified, although the issue on appeal was previously characterized as entitlement to service connection for PTSD. Nevertheless, given that there is no evidence to distinguish between all of the symptoms of the Veteran’s psychiatric disabilities, a separate decision as to entitlement to service connection for psychiatric disability other than major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified is unnecessary. See Howell v. Nicholson, 19 Vet. App. 535, 540 (2006) (explaining that the Secretary must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant’s service-connected disability). Thus, in applying the benefit of the doubt doctrine, all the Veteran’s psychiatric symptoms must, therefore, be attributed to his now service-connected major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (VA must apply the benefit of the doubt doctrine and attribute the inseparable effects of a disability to the claimant’s service-connected disability). 2. Entitlement to service connection for back disability and bilateral neurological disability of the lower extremities The question for the Board is whether the Veteran has 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 finds, for the following reasons, that, while there is evidence that the Veteran has current back disability and bilateral neurological disability of the lower extremities, the claimed disabilities are not shown to have had their onset in service or to be otherwise related to a disease or injury in service. Medical records, including a May 2014 medical report from C.E.M. Quesada, an April 2015 VA primary care note, and the report of a March 2019 VA back examination, show the Veteran experiences degenerative arthritis of the spine, right leg sciatica, and bilateral peripheral neuropathy of the lower extremities. Therefore, current back disability and bilateral neurological disability of the lower extremities are demonstrated. As the Veteran served in Vietnam during the Vietnam War era, he is presumed to have been exposed to herbicide agents, including Agent Orange. 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6)(iii). The Veteran reported on a November 1967 report of medical history form completed for purposes of separation from service that he had a history of recurrent back pain. However, he does not specifically contend, and the evidence does not otherwise reflect, that he has experienced a continuity of back or lower extremity neurological symptomatology in the years since service. In this regard, there is no evidence of any complaints of or treatment for back or lower extremity neurological problems in his service treatment records other than the single November 1967 report of recurrent back pain, and his November 1967 separation examination was normal. Also, the earliest clinical evidence of back and lower extremity neurological problems following service is reflected in an October 2000 VA general medical examination report, which reveals that the Veteran developed low back pain 4 years prior to the October 2000 examination and that he experienced cramps and numbness in his extremities. He was diagnosed as having chronic low back pain/lumbago and lumbar spondylosis. The Veteran submitted a claim of service connection for peripheral neuropathy in September 1996 (see a September 1996 VA Form 21-526). There is no earlier evidence of any back or lower extremity neurological problems following service. The absence of any evidence of back or lower extremity neurological problems for over two decades after the Veteran’s separation from active service in January 1968 is one factor, along with the other evidence noted above, weighing against a finding that his current back and lower extremity neurological disabilities were present in service or in the year or years immediately after service. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (the Board may consider in its assessment of a service connection claim the passage of a lengthy period of time wherein the veteran has not complained of the malady at issue).” As the Veteran’s lower extremity neurological disability did not become manifest to a degree of 10 percent or more within one year after the Veteran’s January 1968 separation from service, much less within one year of when his service in Vietnam ended in August 1967 (see the Veteran’s service personnel records which reflect that he served in Vietnam from August 1966 to August 1967), his lower extremity peripheral neuropathy does not qualify as early-onset peripheral neuropathy, for purposes of presumptive service connection on the basis of herbicide agent exposure under 38 C.F.R. § 3.309(e). In addition, the preponderance of the competent, probative opinions on whether there is a relationship between the Veteran’s current back disability and bilateral lower extremity neurological disability and service weigh against the claim. In his May 2014 medical report, Dr. Quesada opined that the Veteran’s “neurological . . . and “musculoskeletal diseases” were “more probable than not sec[o]ndary to his military service performance and Agent Orange contact.” There was no further explanation or rationale provided for this opinion. The physician who conducted an October 2015 VA neurological examination explained that the Veteran’s bilateral peripheral neuropathy of the lower extremities was of unknown etiology/idiopathic, or could be attributed to aging. His peripheral neuropathy had its onset approximately 10 years prior to the October 2015 examination and the medical evidence did not support the conclusion that this disability existed during service or within the one year period after his separation from service, and it could not be attributed to Agent Orange. The physician who conducted a March 2019 VA back examination opined that it was not likely (“less likely as not”) that the Veteran’s back disability began during service or within one year of his separation from service, or was otherwise etiologically related to service. The physician reasoned that the Veteran’s lumbar spine condition was related to the normal changes of the aging process and developed slowly, but steadily, as a normal aging process. There was no evidence in his service treatment records that he had lumbar spine degenerative changes at the age during which he served in the military. In January 2020, a VA physician reviewed the Veteran’s claims file and opined that his claimed bilateral neurological disability of the lower extremities was not likely (“less likely than not”/“less than 50 percent probability”) incurred in or caused by service. The physician reasoned that the Veteran’s service treatment records were silent for any condition, complaint, or symptoms with a direct nexus to the Veteran’s claimed neurological disability. Therefore, the disability did not begin during service or within one year after his separation from service. The Veteran’s neurological disability was not likely (“less likely”) related to an in-service injury or disease, including herbicide agent/Agent Orange exposure. In January 2020, a second VA physician reviewed the Veteran’s claims file and explained that his low back disability was related to the normal changes of the aging process and that it developed slowly, but steady, as a normal aging process. Imaging studies correlated with the normal atraumatic changes commensurate with the Veteran’s present age. Although the Veteran reported back pain on the November 1967 report of medical history form completed for purposes of separation from service, he was 21 years of age at that time and degenerative changes are not common at that age range. Also, his service treatment records were silent for objective evidence of any degenerative changes during service. In order to suspect that that current lumbar spine disability had its onset during service (and specifically at the time the Veteran reported back pain in November 1967 at the age of 21), it must have been secondary to trauma. However, the Veteran’s lumbar spine disability was atraumatic and related to the aging process, as seen in objective studies. Dr. Quesada’s May 2014 opinion is of minimal probative value because it is unclear whether he examined the Veteran or otherwise reviewed any of his treatment records. Moreover, the opinion is not accompanied by any specific explanation or rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The October 2015 opinion is also of minimal probative value because it is partially based upon an inaccurate history. Specifically, the physician explained that the Veteran’s neuropathy had its onset approximately 10 years prior to the October 2015 examination. As explained above, however, he reported that experienced cramps and numbness in his extremities during the October 2000 VA general medical examination. Therefore, the October 2015 opinion is partially based on an inaccurate history and is of little probative value. Monzingo, 26 Vet. App. at 107. Moreover, the March 2019 opinion is also of limited probative value because the physician did not acknowledge or comment upon the potential significance of the Veteran’s report of back pain on the November 1967 report of medical history form. The January 2020 opinions, by contrast, are based upon a review of the Veteran’s treatment records and consideration of his reported history, and they are accompanied by specific rationales that are consistent with the evidence of record. Therefore, the January 2020 opinions are adequate and entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. Moreover, lay evidence may be competent on a variety of matters concerning the nature and cause of disability. However, the dispositive questions presented in this case (i.e., whether any relationship exists between the Veteran’s claimed back disability and bilateral neurological disability of the lower extremities and service) are questions as to internal medical processes which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. See Jandreau, 492 F.3d at 1377 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). Opinions as to whether there is a link between the Veteran’s claimed back disability and bilateral neurological disability of the lower extremities and service (where there is no evidence of any back or lower extremity neurological problems for decades after service) are ones requiring specialized knowledge and testing to understand the complex nature of the body systems. The Veteran has not indicated that he has such experience. His opinion on the question of nexus is therefore not competent evidence in this instance. There is no other evidence of a relationship between the Veteran’s current back disability and bilateral neurological disability of the lower extremities and service, and neither he nor his representative have alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran’s back disability or bilateral neurological disability of the lower extremities had their onset in service or within the first post-service year, or that they are otherwise related to service. For the foregoing reasons, the preponderance of the evidence is against the claim. The benefit-of-the-doubt doctrine is therefore not for application, and service connection for back disability and bilateral neurological disability of the lower extremities is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for bilateral eye disability is remanded. The Veteran was afforded a VA eye examination in July 2019 and was diagnosed as having bilateral open angle glaucoma, bilateral senile cataracts, right eye nasal and temporal pterygium, and left eye nasal recurrent pterygium. The physician who conducted the examination opined that the Veteran’s glaucoma was not related to service. The examiner reasoned, in pertinent part, that the Veteran was diagnosed with ocular hypertension/open angle glaucoma in 2009, more than 40 years after his separation from service. The July 2019 opinion is inadequate because the examiner only provided an opinion as to whether the Veteran’s glaucoma was related to service and did not address any of his other currently diagnosed eye disabilities. Moreover, although the examiner reasoned that the Veteran did not experience glaucoma until 2009, there is evidence of eye problems as early as a May 1992 VA general medical examination, which indicates that the Veteran had bilateral pterygium and senile arch and had surgery for a left eye pterygium 10 years prior to the May 1992 examination. In light of the inadequacies of the July 2019 opinion, a remand is necessary to obtain a new medical opinion as to whether any current eye disability is related to service. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the VA Caribbean Healthcare System and are dated to September 2020. Any VA treatment records are within VA’s constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. 2. Entitlement to service connection for sleep disability is remanded. In the June 2019 remand, the Board instructed the AOJ to afford the Veteran a VA examination to obtain a medical opinion as to whether the Veteran’s sleep disorder was related to service. Pursuant to the Board’s remand, the Veteran was afforded a VA sleep apnea examination in September 2020. The examiner concluded that the Veteran did not have sleep apnea and that there was no evidence of treatment for or a diagnosis of a sleep disorder. Therefore, no opinion was provided as to whether any sleep disability was related to service. The September 2020 examination is inadequate because it largely focuses on whether the Veteran had sleep apnea, as opposed to any other sleep disorder. Although the examiner concluded that there was no evidence of any sleep disorder, the Veteran’s medical records reflect that he has reported sleep problems on numerous occasions during the claim period. Moreover, the Board is awarding service connection for major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified, and the Veteran has reported sleep impairment associated with his now service-connected psychiatric disability. In light of the above, a remand is necessary to obtain a new medical opinion as to whether any of the sleep symptoms experienced by the Veteran are indicative of a separate and distinct sleep disability (not limited to just sleep apnea), or are symptoms of his now service-connected psychiatric disability. Also, all outstanding VA treatment records should be secured upon remand. 3. Entitlement to service connection for bilateral knee disability is remanded. In January 2020, a VA physician reviewed the Veteran’s claims file and opined that the Veteran’s claimed bilateral knee disability (diagnosed as bilateral degenerative osteoarthritis and left suprapatellar calcific tendinosis) was not likely incurred in or caused by service. The physician reasoned that there was no evidence of these specific knee diagnoses during service or within one year after the Veteran’s separation from service. The January 2020 opinion is inadequate because it is predominantly based on the absence of diagnosed degenerative osteoarthritis of the knees and left knee suprapatellar calcific tendinosis during service or within one year of service, and the physician did not acknowledge or discuss the Veteran’s right knee injury in November 1966 when he dropped an item on the knee or his report of knee problems on the November 1967 report of medical history form completed for purposes of separation from service. Therefore, an appropriate medical opinion should be obtained upon remand. Also, all outstanding VA treatment records should be secured upon remand. 4. Entitlement to service connection for left hip disability is remanded. In the October 2019 remand, the Board explained that a March 2019 VA hip examination was inadequate because although the examiner concluded that the Veteran did not have any left hip disability, there was evidence of left hip pain in his VA treatment records and Dr. Quesada diagnosed the Veteran as having left hip osteoarthritis in his May 2014 medical report. Therefore, the Board instructed the AOJ to obtain a medical opinion as to whether any current left hip disability (including hip pain) was related to service. Pursuant to the Board’s remand, a VA physician reviewed the Veteran’s claims file in March 2020. However, the physician only concluded that an opinion as to whether any current left hip disability was related to service could not be provided because no left hip disability was found during the March 2019 hip examination. Therefore, a remand is necessary to obtain a new medical opinion as to whether the Veteran’s claimed left hip disability is related to service. Also, all outstanding VA treatment records should be secured upon remand. 5. Entitlement to a TDIU due to service-connected disabilities is remanded. Since the AOJ’s implementation of the Board’s award of service connection for major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified and a decision on the remanded service connection issues could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim for a TDIU is required. Also, all outstanding VA treatment records should be secured upon remand. The matters are REMANDED for the following action: 1. Implement the Board’s award of service connection for major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified, to include the assignment of an initial disability rating. 2. Obtain the Veteran’s outstanding VA treatment records from the VA Caribbean Healthcare System for the period since September 2020; and all such relevant records from any other sufficiently identified VA facility. 3. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any eye disability experienced by the Veteran since approximately May 2014 (including, but not limited to, glaucoma, cataracts, and pterygium) at least as likely as not (1) began during active service; OR (2) is related to an injury or disease during service, including his presumed exposure to herbicide agents (including Agent Orange). For purposes of the above opinion, the clinician shall presume that any reports by the Veteran of eye problems in service are accurate. The clinician must provide reasons for each opinion given. In this regard, the fact that a particular eye disability is not on the list of diseases presumed to be associated with exposure to Agent Orange should not be the basis for a negative opinion. 4. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any knee disability experienced by the Veteran since approximately May 2014 at least as likely as not (1) began during active service; (2) manifested within one year after separation from active service (in the case of any currently diagnosed arthritis); OR (3) is related to an injury or disease during service, including the knee injury in November 1966 documented in his service treatment records and his report of knee problems on the November 1967 report of medical history form completed for purposes of separation from service. The clinician is advised that although the Veteran reported a history of knee problems prior to service on his September 1965 report of medical history form completed for purposes of entrance into service, he was presumed sound at service entrance. For purposes of the above opinion, the clinician shall presume that any reports by the Veteran of knee problems in service are accurate. The clinician must provide reasons for each opinion given. 5. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any sleep disability experienced by the Veteran since approximately May 2014 (not limited to sleep apnea) at least as likely as not (1) began during active service; (2) is related to an injury or disease during service, including his presumed exposure to herbicide agents (including Agent Orange); (3) is caused by service-connected major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified; OR (4) is aggravated by service-connected major depressive disorder, major depression with psychotic features, and cognitive disorder unspecified. For purposes of the above opinion, the clinician shall presume that any reports by the Veteran of sleep problems in service are accurate. The clinician must provide reasons for each opinion given. In this regard, the fact that a particular sleep disability is not on the list of diseases presumed to be associated with exposure to Agent Orange should not be the basis for a negative opinion. 6. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any left hip disability experienced by the Veteran since approximately May 2014 (including, but not limited to, the hip osteoarthritis diagnosed by Dr. Quesada in his May 2014 medical report and the hip pain experienced during the period since May 2014) at least as likely as not (1) began during active service; (2) manifested within one year after separation from active service; OR (3) is related to an injury or disease during service. For purposes of the above opinion, the clinician shall presume that any reports by the Veteran of left hip problems in service are accurate. The clinician must provide reasons for each opinion given. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Elwood, 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.