Citation Nr: 21023653 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 16-15 760 DATE: April 21, 2021 ORDER Entitlement to service connection for sleep apnea, to include secondary service connection to service-connected coronary artery disease is granted. Entitlement to a rating in excess of 30 percent for coronary artery disease for the period prior to September 16, 2019, is denied. Entitlement to a rating in excess of 60 percent for coronary artery disease for the period starting September 16, 2019, is denied. Entitlement to a rating in excess of 20 percent for diabetes mellitus is denied. Entitlement to an effective date earlier than July 12, 2018, for the award of service connection for diabetes mellitus is denied. REMANDED Entitlement to service connection for hypertension, to include exposure to Agent Orange and in the alternative, secondary service connection to service-connected post-traumatic stress disorder (PTSD) is remanded. Entitlement to service connection for gastro-esophageal reflux disorder (GERD), to include, secondary service connection to service-connected post-traumatic stress disorder (PTSD) or diabetes mellitus is remanded. FINDINGS OF FACT 1. Resolving all doubt in the Veteran’s favor, the Veteran has obstructive sleep apnea is related to his service-connected coronary artery disease. 2. Prior to September 16, 2019, the Veteran’s coronary artery disease was characterized by a left ventricular ejection of 78 percent. 3. Starting September 16, 2019, the Veteran’s coronary artery disease was characterized by a workload of greater than 3 METs but not greater than 5 METs resulting in dyspnea, angina and fatigue. 4. The Veteran’s diabetes has not required regulation of activities or daily insulin injection as contemplated by VA regulation. 5. On July 12, 2018, the Veteran filed a supplemental claim seeking service connection for diabetes. It is not factually ascertainable that the Veteran had either diabetes prior to that date. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea, as secondary to service-connected coronary artery disease, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. For the period prior to September 16, 2019, the criteria for entitlement to a rating in excess of 30 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.104, Diagnostic Code 7005. 3. For the period starting September 16, 2019, the criteria for entitlement to a rating in excess of 60 percent for coronary artery disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.10, 4.14, 4.104, Diagnostic Code 7005. 4. The criteria for entitlement to a rating in excess of 20 percent for diabetes mellitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.119 Diagnostic Code (DC) 7913. 5. The criteria for an effective date earlier than July 12, 2018, for the award of service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 5101, 5107, 5110; 38 C.F.R. §§ 3.102, 3.151, 3.155, 3.159, 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served with the United States Army from June 1970 to February 1972. These matters come before the Board of Veterans’ Appeals (Board) on appeal from 2015 and 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Several of the matters on appeal were previously remanded by the Board of Veterans’ Appeals (Board) in October 2018. The Board’s October 2018 remand directives and the subsequent actions of the AOJ will be discussed below. The Veteran’s appeal has been returned to the Board for further appellate consideration.  Service Connection 1. Entitlement to service connection for sleep apnea, to include secondary service connection to service-connected coronary artery disease is granted. As an initial matter, the Board previously remanded the Veteran’s claim for additional development, including a VA examination to address the Veteran’s secondary service connection theory that his sleep apnea was caused or aggravated by his PTSD. However, the Veteran also submitted remarks to his March 2016 Statement of Case and argued his sleep apnea condition qualified for secondary service connection to his service-connected coronary artery disease. See May 2017 Medical Treatment Record. Secondary service connection under this theory is warranted for the reasons listed below. In order to prevail on a claim of service connection, generally, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d) (2018). Service connection may also 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) (2018). 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. 38 C.F.R. § 3.310(b) (2018); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. Obesity, however, can be considered "an intermediate step" for service-connection if the evidence shows that a service-connected disability "caused the veteran to become obese" and the obesity caused by the service connected disability "was a substantial factor in causing" the current disability, and that the current disability "would not have occurred but for" the obesity caused by the service-connected disability." VA Off. Gen. Couns. Prec. Op. 1-2017. With regard to a current disability, the Veteran has a diagnosis of obstructive sleep apnea since March 2019. See July 2020 VA examination. Thus, the first element of Wallin is met. Regarding secondary service connection, the Board notes that the Veteran has been service connected for coronary artery disease. See May 2015 Rating Decision. Thus, the second element of Wallin is met. The remaining question is whether there is a medical nexus between the Veteran’s current disability for sleep apnea and his service-connected coronary artery disease. The Veteran submitted a private medical opinion in June 2016. The private examiner concluded it was more likely than not the Veteran’s obstructive sleep apnea due to his service-connected coronary artery disease. She reasoned that the Veteran had gained 22 pounds since his myocardial infarction and that severe obstructive sleep apnea was much more likely to be present in patients with a high body mass index. Further, the Veteran was required to be on medications since his myocardial infarction and diagnosis of coronary artery disease which also have side effects of weight gain, shortness of breath, fatigue, weakness, labored, and troubled breathing. A September 2020 VA opinion report reflects the VA examiner’s opinion that the Veteran’s obesity is not a result of his heart condition or a substantial factor in causing his sleep apnea, because the heart disease alone did not cause him to become obese, purely on the lack of an 'inability to exercise.' The examiner discussed the many lifestyle factors, such as alcoholism and diet, and non-heart disease related risks that were also at play. The examiner further noted that the Veteran’s obesity is the most likely cause of his sleep apnea. In Walsh v. Wilkie, the Court further held, that the Board needs to consider the obesity-intermediate step theorem predicated on aggravation where appropriate. Thus, the Court held that proper interpretation of G.C. Prec. Op. 1-2017 requires consideration of both proximate causation and aggravation in its analytical framework: (1) whether the service-connected disability (caused the veteran to become obese/aggravated the veteran's obesity); (2) if so, whether the (obesity/aggravation of obesity) as a result of the service-connected disability was a substantial factor in causing the current disability; and (3) whether the current disability would not have occurred but for (obesity caused/obesity aggravated) by the service-connected disability. If these questions are answered in the affirmative, then the current disability may be service connected on a secondary basis. Walsh v. Wilkie, 32 Vet. App. 300 (2020). In this case, the VA examiner indicated that the Veteran’s coronary artery disease did not cause his obesity; however, aggravation was not specifically addressed. The private physician, on the other hand, noted a specific increase in weight gain following the heart attack, implicating that his obesity was aggravated by his coronary artery disease. Thus, in light of the forgoing, the Board finds the evidence in relative equipoise as to a causal relationship between Veteran’s coronary artery disease and his obesity. Moreover, the VA examiner specifically indicated that the Veteran’s sleep apnea is due to his obesity, establishing that sleep apnea “would not have occurred but for the obesity caused by the service-connected coronary artery disease. Therefore, resolving all reasonable doubt in the Veteran’s favor, service connection for sleep apnea secondary to service-connected coronary artery disease is warranted. Increased Rating for Coronary Artery Disease The Veteran was initially service connected for coronary artery disease at a rating of 10 percent effective December 16, 2013. See May 2015 Rating Decision. The Veteran appealed this rating and the Veteran’s initial rating was increased from 10 percent to 30 percent effective December 16, 2013. See March 2016 Rating Decision. The Veteran actively appealed this rating and argued he was entitled to a higher rating. In an October 2018 Board remand, the RO was instructed to obtain a VA examination to assess the severity of the Veteran’s coronary artery disease. Based on the findings of the additional development, the Veteran’s rating was increased from 30 percent to 60 percent effective September 16, 2019. The RO noted that this was a partial grant. See June 2020 Rating Decision. The Veteran contends that he is entitled to an increased rating for his coronary artery disease for his previously assigned 30 percent rating for the period prior to September 16, 2019 and his currently assigned 60 percent rating for the period thereafter. The Veteran’s coronary artery disease has been evaluated under the provisions of 38 C.F.R. § 4.104, Diagnostic Code (DC) 7005. Under DC 7005, a 30 percent rating is assigned when workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness or syncope, or; evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram or X-ray. A 60 percent rating is assigned for more than one episode of acute congestive heart failure in the past year, or; workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of 30 to 50 percent. A 100 percent rating is assigned for chronic congestive heart failure, or; workload of 3 METs or less results in dyspnea, fatigue, angina, dizziness, or syncope, or; left ventricular dysfunction with an ejection fraction of less than 30 percent. One MET (metabolic equivalent) is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. When the level of METs at which dyspnea, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in dyspnea, fatigue, angina, dizziness, or syncope may be used. 38 C.F.R. § 4.104, Note (2). The Court has held that “staged” ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). In this case, staged ratings for the disability on appeal have already been assigned; therefore, the Board will discuss the propriety of the ratings assigned at each stage. 2. Entitlement to a rating in excess of 30 percent for coronary artery disease for the period prior to September 16, 2019 is denied. For this appeal period, the Veteran’s rating for coronary artery disease was increased in a March 2016 Rating Decision pursuant to Diagnostic Code 7005 with an evaluation of 30 percent effective December 16, 2013. See March 2016 Rating Decision. Turning to the evidence, a private stress test dated in March 2013 revealed METs of 6.40 and normal left ventricular function. An April 2014 private disability benefits questionnaire reflects no indication of congestive heart failure. The Veteran was afforded a VA examination in April 2015. The Veteran did not have congestive heart failure at the time of the examination. The examiner did not conduct an interview based METs test because the Veteran denied experiencing symptoms attributable to a cardiac condition with any level of physical activity. A December 2012 echocardiogram showed a left ventricular ejection of 78 percent. See April 2015 VA examination. Based on the evidence described above, the Board finds that the Veteran’s coronary artery disease does not warrant an evaluation higher than 30 percent prior to September 16, 2019. Over the course of the appellate period, the evidence does not show congestive heart failure, a workload of greater than 3 METs but not greater than 5 METs or left ventricular dysfunction with an ejection fraction of 50 percent or less. Instead, the Veteran had an ejection fraction of 78 percent. Further, the Veteran denied exercising symptoms attributable to a cardiac condition with any level of physical activity and therefore does not have METs results from the 2015 VA examination, and the 2013 report noted METs of 6.40. Moreover, the Veteran did not have congestive heart failure at the time of the examination. The evidence most closely approximates that required for a 30 percent disability rating. As such, an initial rating in excess of 30 percent is not warranted. As the preponderance of the evidence is against an increased schedular rating, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107(b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to a rating in excess of 60 percent for coronary artery disease for the period starting September 16, 2019, is denied. For this appeal period, the Veteran’s 30 percent rating to 60 percent based on the results of the September 2019 VA examination. See June 2020 Rating Decision. The Board notes that this is a partial grant and an evaluation for an increased rating for the period starting September 16, 2019, is still warranted. Turning to the evidence, the Veteran was afforded a VA examination in September 2019. At the time of examination, the Veteran complained of chest pain burning with any exertion and fatigue. The examiner indicated that the Veteran did not have congestive heart failure. A December 2012 echocardiogram showed a left ventricular ejection fraction of 60 percent. The interview based METs test showed that a workload between 3 and 5 METs caused dyspnea, fatigue and angina. See September 2019 VA examination. The Board finds that the evidence preponderates against a finding of entitlement to a rating in excess of 60 percent for coronary artery disease for the period starting September 16, 2019. To warrant a higher rating, the evidence must show chronic congestive heart failure; a workload of 3 METs or less resulting in dyspnea, fatigue, angina, dizziness, or syncope; or, a left ventricular ejection fraction of 30 percent or less. The Board acknowledges the Veteran’s testimony that chest pain burning with any exertion and fatigue. However, this level of disability is not reflected in his extensive treatment records for the period remaining on appeal. The medical evidence of record demonstrates that the Veteran experienced dyspnea, fatigue, and angina from a workload of greater than 3 METs as a result of his coronary artery disease. Further, the examiner did not have congestive heart failure at the time of the examination and had a left ventricular ejection of 60 percent. These manifestations are contemplated by the current 60 percent rating; accordingly, a rating in excess of 60 percent for coronary artery disease is not warranted for the period starting September 16, 2019. As the preponderance of the evidence is against an increased schedular rating, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107(b); see Gilbert, 1 Vet. App. at 49. Increased Rating for Diabetes Mellitus 4. Entitlement to a rating in excess of 20 percent for diabetes mellitus is denied. The Veteran was service connected for diabetes at a rating of 20 percent effective July 12, 2018. See September 2018 Rating Decision. The Veteran’s diabetes is evaluated as 20 percent disabling under DC 7913. In September 2019, the Veteran filed a claim for an increased rating for this disability. Disability evaluations are determined by comparing a Veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran’s condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of its entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, “staged” ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Under DC 7913, a 20 percent rating is assigned for diabetes mellitus requiring insulin and restricted diet, or oral hypoglycemic agent and restricted diet. A 40 percent rating is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities. A 60 percent rating is assigned for diabetes mellitus requiring insulin, restricted diet, and regulation of activities with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalizations per year or twice a month visits to a diabetic care provider, plus complications that would not be compensable if separately evaluated. A 100 percent rating is assigned for diabetes mellitus requiring more than one daily injection of insulin, restricted diet, and regulation of activities (avoidance of strenuous occupational and recreational activities) with episodes of ketoacidosis or hypoglycemic reactions requiring at least three hospitalizations per year or weekly visits to a diabetic care provider, plus either progressive loss of weight and strength or complications that would be compensable if separately evaluated. The term “regulation of activities” is specifically defined as “avoidance of strenuous occupational and recreational activities” with the intention of avoiding hypoglycemic episodes. See Camacho v. Nicholson, 21 Vet. App. 360, 363-364 (2007); see also VBA Manual M21-1, III.iv.4.M.1.e. Information on Regulation of Activities. Medical evidence is required to support this criterion; a medical provider must indicate that the claimant’s “diabetes is of such severity that he should curtail his activities such as to avoid strenuous activity.” Camacho, 21 Vet. App. at 364. DC 7913 evaluates diabetes mellitus based on successive rating criteria. The evaluation for each higher disability rating includes the criteria of each lower disability rating, such that if a component is not met at any one level, the veteran can only be rated at the level that does not require the missing component. Tatum v. Shinseki, 23 Vet. App. 152, 156 (2009). For example, the 10 percent evaluation for diabetes mellitus requires a restricted diet; the 20 percent evaluation requires a restricted diet and insulin or oral hypoglycemic agent; the 40 percent evaluation requires insulin, restricted diet, and regulation of activities; and so forth. Camacho, 21 Vet. App. at 366; see also VBA Manual M21-1, III.iv.4.M.1.d. Successive Criteria Requirement for the Next Higher Disability Evaluation. Turning to the evidence, the Veteran was afforded a VA examination in September 2018. The examination report indicated that the Veteran managed his diabetes with a restricted diet and prescribed oral hypoglycemic agents. Additionally, the Veteran did not require regulation of activities as part of his medical management or insulin injections. See September 2018 VA examination. The Board finds that the weight of the evidence preponderates against a finding of entitlement to a rating in excess of 20 percent for diabetes mellitus. To receive a higher evaluation, the Veteran’s diabetes mellitus would need to require insulin and regulation of activities with the intention of avoiding hypoglycemic episodes. The evidence fails to demonstrate that the Veteran’s activities were regulated for the purposes of avoiding hypoglycemic episodes or that he required insulin injections. Rather, the Veteran’s disability was managed with medication and a restricted diet. As the predominant characteristics of the Veteran’s diabetes mellitus are contemplated by the assigned 20 percent rating, an increased rating is not warranted. As the preponderance of the evidence is against an increased schedular rating, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107(b); see Gilbert, 1 Vet. App. at 49. Earlier Effective Date 5. Entitlement to an earlier effective date for the award of service connection for diabetes mellitus is denied. Generally, the effective date for an award based on an original claim, claim reopened after a final disallowance, or claim for an increased rating, is the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. For increased ratings, an effective date may be awarded based on the earliest date as of which it is factually ascertainable that an increase occurred if such date is within one year prior to the receipt of the claim. 38 C.F.R. § 3.400(o)(2). A claim for VA compensation must generally be in the form prescribed by the VA Secretary. See 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). Effective March 24, 2015, claims are required to be filed on standard forms, thus eliminating constructive receipt of claims and informal claims. See 79 Fed. Reg. 57660 (Sept. 25, 2014). Prior to March 24, 2015, a “claim” was defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication or action, however, received from the claimant, or certain specified individuals on the claimant’s behalf, that indicated intent to apply for a benefit, and identified that benefit, could be considered an informal claim. 38 C.F.R. § 3.155(a). The record shows the Veteran first filed an informal claim on September 10, 2014, and generally stated that he intended to apply for compensation benefits and that this statement was intended to preserve his effective date for entitlement to benefits. The Veteran did not state any specific conditions. See September 2014 Statement in Support of Claim. On October 8, 2014, VA acknowledged that it had received an intent to file a claim for compensation; however, the RO noted in order to start processing his claim, he had to submit a VA Form 21-526EZ. See October 2014 Correspondence. On October 30, 2014, the Veteran submitted another general informal claim to establish and preserve his effective date. See October 2014 Statement in Support of Claim. On November 2014, VA acknowledged that it had received an intent to file a claim for compensation; however, the RO noted in order to start processing his claim, he had to submit a VA Form 21-526EZ. See November 2014 Development Letter. In December 2014, the Veteran submitted a VA Form 21-526 EZ seeking compensation for hearing loss, tinnitus, PTSD, alcoholism, acid reflux, a heart condition, and joint pain; diabetes mellitus was not among the listed conditions. On July 12, 2018, the Veteran filed a supplemental claim for service connection for diabetes. See July 2018 Supplemental Claim. The Board finds that there is no communication of record that could serve as the basis for an earlier effective date under See 38 U.S.C. § 5101(a) prior to July 12, 2018. Therefore, the Veteran’s July 12, 2018, supplemental claim is the proper effective date of claim for the Veteran’s service-connected diabetes. The Board has considered whether entitlement to an earlier effective date is warranted on another basis. Because regulations require an effective date for service connection to be the date of claim or the date entitlement arose, whichever is later, the critical issue is whether the Veteran’s diabetes existed prior to his July 12, 2018 claim for service connection. The Board finds there is no evidence of a diagnosis or treatment for the Veteran’s diabetes prior to July 12, 2018. Further, the Veteran has not raised any specific contentions in regard to his claim for an earlier effective dates. After reviewing the record, the Board finds the criteria for an effective date prior to July 12, 2018, for the award of service connection for diabetes mellitus have not been met. See 38 C.F.R. § 3.400. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include exposure to Agent Orange and in the alternative, secondary service connection to service-connected post-traumatic stress disorder (PTSD) is remanded. 2. Entitlement to service connection for gastro-esophageal reflux disorder (GERD), secondary service connection to service-connected post-traumatic stress disorder (PTSD) and diabetes mellitus is remanded. The Board previously remanded this matter in October 2018 for further development, including a VA examination. Regarding the VA examination, the examiner was directed to provide secondary service connection opinions for the Veteran’s claims for hypertension and GERD. See October 2019 Board Decision. Following the October 2018 Board remand, the Veteran was afforded a VA examination to address the Veteran’s hypertension and GERD. These resulting examinations provided negative secondary service connection opinions for all the Veteran’s claims. However, the Veteran’s representative provided new contentions for the Veteran’s claim that have not been considered by previous examiners. The Veteran’s representative argued in his September 2020 Correspondence that the Veteran’s service-connected PTSD may have caused him to gain weight and that this weight gain, in turn, caused him to develop hypertension and GERD. See September 2020 Correspondence. As noted above, although obesity cannot be service-connected on a direct basis and cannot qualify as an in-service event for service connection purposes, it may serve as an “intermediate step” between a service-connected disability and a current disability that may be service-connected on a secondary basis. VAOGCPREC 1-2017. In light of the Veteran’s representative’s assertions in this regard and the other evidence of record, the Board finds that a medical opinion addressing this theory must also be obtained on remand.  Additionally, the Veteran’s representatives expressed that the Veteran’s hypertension or GERD could be related to his now service-connected sleep apnea. The representative referenced an article which found sleep apnea causes a sudden drop in oxygen levels which increases blood pressure. Additionally, the Veteran’s representative also argued that the Veteran’s GERD could be related to the Veteran’s service-connected diabetes. The representative noted that studies showed a significant association between diabetes and GERD. See September 2020 Correspondence. The Veteran has not been afforded a VA examination which address these contentions; thus, remand is required. Moreover, the Veteran’s representative argue that the Veteran’s hypertension could be caused by exposure to Agent Orange. The Veteran does not have an examination of record which considers this contention. Especially in light of an article referenced by the Veteran’s representative in the September 2020 correspondence from the National Academies of Sciences, Engineering, and Medicine (NAS) noting an association between Agent Orange and hypertension, the Board finds that on remand, a new opinion as to direct service connection is required as well. See September 2020 Correspondence. In sum, the Board finds that an additional examination is necessary in order to fully consider the evidence of record. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain an opinion, it must ensure that the examination or opinion is adequate). The matters are REMANDED for the following action: Obtain an addendum VA medical opinion for the Veteran’s hypertension and GERD. If deemed necessary by the examiner, afford the Veteran a VA examination. After eliciting a history of the Veteran’s disabilities, the examiner should offer comments, an opinion and a supporting rationale for the following: (a.) With regard to the Veteran’s hypertension, the VA examiner should offer the following opinion: 1. Is the Veteran’s hypertension at least as likely as not related to exposure to herbicides, to include Agent Orange, as a result of his service in Vietnam? The examiner must specifically address the recent NAS report indicating that there is “sufficient” evidence of an association between hypertension and herbicide exposure. See September 2020 Correspondence. 2. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s current hypertension was either caused or aggravated by his service-connected PTSD? 3. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s current hypertension was either caused or aggravated by his service-connected sleep apnea? The examiner must address the Veteran’s contention that obstructive sleep apnea is a recognized cause of hypertension. The examiner should consider the article the Veteran’s representative referenced which found sleep apnea causes a sudden drop in oxygen levels which increases blood pressure. See September 2020 Correspondence. 4. If you found no causation or aggravation in question (1.), (2.), or (3.), above, is it at least as likely as not (50 percent probability or greater) that the Veteran’s PTSD either (1) caused him to become obese/gain weight or (2) aggravated his obesity/weight gain? Please explain why or why not.  5. If the Veteran’s PTSD was at least as likely as not caused or aggravated the Veteran’s obesity/weight gain, was the obesity or aggravation of obesity a substantial factor in causing his hypertension?  Please explain why or why not.  The examiner must address the Veteran’s representative’s contention which found obesity was a risk factor for hypertension and that PTSD had caused substantial weight gain. See September 2020 Correspondence. (b.) With regard to the Veteran’s GERD, the VA examiner should offer the following opinion: 1. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s current GERD was either caused or aggravated by his service-connected diabetes? The examiner should address the Veteran’s representative contention that studies show a significant association between diabetes mellitus and GERD. See September 2020 Correspondence. 2. Is it at least as likely as not (50 percent probability or greater) that the Veteran’s current GERD was either caused or aggravated by his service-connected PTSD? The examiner should address the Veteran’s representative’s contention that depression and treatment with antidepressants are associated with the development GERD, specifically, there was a link between the presence of reflux symptoms and the use of antipsychotic drugs. See September 2020 Correspondence. 3. If you found no causation or aggravation in question (1.) or (2.), above, is it at least as likely as not (50 percent probability or greater) that the Veteran’s PTSD either (1) caused him to become obese/gain weight or (2) aggravated his obesity/weight gain? Please explain why or why not. 4. If the Veteran’s PTSD was at least as likely as not caused or aggravated the Veteran’s obesity/weight gain, was the obesity or aggravation of obesity a substantial factor in causing his hypertension?  Please explain why or why not. The examiner should address the articles the Veteran submitted which note that obesity is a risk factor for GERD and the evidence for a link between psychiatric medications and the presence of reflux symptoms. See September 2020 Correspondence. G. E. Wilkerson Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Emily A. Kotroco 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.