Citation Nr: 21023753 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 17-50 289A DATE: April 21, 2021 ORDER New and material evidence having been received, the application to reopen the previously denied claim of service connection for a lung disability is granted. New and material evidence having been received, the application to reopen the previously denied claim of service connection for bilateral pes planus is granted. Service connection for bilateral pes planus is granted. Service connection for obstructive sleep apnea is granted. Service connection for anemia is denied. Service connection for a thyroid disability is denied. REMANDED Entitlement to service connection for a lung disability is remanded. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. Entitlement to service connection for vertigo is remanded. Entitlement to service connection for residuals of cold weather injury of left upper extremity is remanded. Entitlement to service connection for residuals of cold weather injury of right upper extremity is remanded. Entitlement to service connection for residuals of cold weather injury of left lower extremity is remanded. Entitlement to service connection for residuals of cold weather injury of right lower extremity is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In an unappealed November 1978 rating decision, the RO denied service connection for a lung disability; evidence received since then relates to an unestablished fact and raises a reasonable possibility of substantiating the claim. 2. In an unappealed November 1978 rating decision, the RO denied service connection for bilateral pes planus; evidence received since then relates to an unestablished fact and raises a reasonable possibility of substantiating the claim. 3. Resolving all reasonable doubt in the Veteran’s favor, bilateral pes planus is manifested as a result of his period of active service. 4. The preponderance of the evidence is against finding that anemia began during active service, or is otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that a thyroid disability began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The unappealed November 1978 rating decision that denied service connection for a lung disability is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence having been received, the claim of entitlement to service connection for a lung disability is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The unappealed November 1978 rating decision that denied service connection for bilateral pes planus is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 4. New and material evidence having been received, the claim of entitlement to service connection for bilateral pes planus is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 5. The criteria for service connection for bilateral pes planus have been met. 38 U.S.C. §§ 1110, 5103, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for anemia are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for a thyroid disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1974 to September 1976. This matter is before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA), Regional Office (RO). In August 2015, the RO denied service connection for obstructive sleep apnea, PTSD, and residuals of frostbite of the bilateral upper and lower extremities. The RO also determined that new and material evidence had not been received to reopen the previously denied claim of service connection for a lung disability. The Veteran timely filed a notice of disagreement with this decision in September 2015. In October 2016, the RO notified the Veteran that the signature page of the notice of disagreement had apparently not been received, and that the time in which to file a notice of disagreement had expired. The Veteran timely filed a notice of disagreement as to the issue regarding the timeliness of the notice of disagreement. However, in March 2018, the RO determined that the September 2015 notice of disagreement had been timely filed by the Veteran, thus, the August 2015 rating decision did not become final. This matter also arises from an April 2017 rating decision of the RO that denied service connection for anemia, hypothyroidism, and vertigo; a July 2017 RO decision that continued a prior denial of service connection for bilateral pes planus; and an October 2017 RO decision that denied a TDIU. It is noted that the Veteran had filed a claim of entitlement to service connection for PTSD. The evidence of record shows that the Veteran has over the course of this appeal exhibited symptoms related to additional psychiatric disorders. A claim for a psychiatric disorder encompasses all claims for service connection for all psychiatric disabilities. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). As such, the issue has been recharacterized as entitlement to service connection for a psychiatric disorder, to include PTSD. In October 2020, the Veteran testified at a personal hearing over which the undersigned Veterans Law Judge presided. A transcript of the hearing is of record. Service Connection Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. In order to prevail on the issue of service connection for a disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Service connection for certain chronic diseases may also be established based upon a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a), (b); Allen v. Brown, 7 Vet. App. 439 (1995). Although an unappealed decision is final, a claim will be reopened if new and material evidence is received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. New and material evidence can be neither cumulative, nor redundant, of the evidence of record at the time of the last prior final denial of the claim sought to be reopened; and must raise a reasonable possibility of substantiating the claim. “New” evidence means existing evidence not previously submitted to VA. “Material” evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an un-established fact necessary to substantiate the claim. See 38 C.F.R. § 3.156 (a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. When evaluating the materiality of newly submitted evidence, the focus must not be solely on whether the evidence remedies the principal reason for denial in the last prior decision; rather the determination of materiality should focus on whether the evidence, taken together, could at least trigger the duty to assist or consideration of a new theory of entitlement. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). If the claim is reopened, it will be reviewed on a de novo basis. 38 U.S.C. §§ 5108, 7105; Evans v. Brown, 9 Vet. App. 273, 282-83 (1996); Manio v. Derwinski, 1 Vet. App. 140 (1991). 1. Whether new and material evidence having been received to reopen the previously denied claim of service connection for a lung disability. The Veteran contends that he has a lung disability that is manifested as a result of his period of active service. The Veteran’s claim of service connection was initially denied by the RO in November 1978. The Veteran did not appeal the decision and did not remit any submissions to the RO which contained new and material evidence pertaining to the claim prior to the expiration of the appellate period. See 38 C.F.R. § 3.156 (b); Bond v. Shinseki, 659 F.3d 1362, 1367-8 (Fed. Cir. 2011); see also Beraud v. McDonald, 766 F. 3d 1402 (Fed. Cir. 2014) (Receipt of new and material evidence within the appeal period of an unappealed agency of original jurisdiction decision vitiates finality until VA addresses such evidence.) Thus, the November 1978 rating decision with respect to this issue became final. The evidence of record at the time of the November 1978 RO decision included the Veteran’s service treatment records that showed the Veteran was treated on numerous occasions for upper respiratory infection and chest pain. In this regard, in November 1974, he was treated for acute respiratory disease. In December 1974, he was treated for an upper respiratory infection. In August 1975, he expressed difficulty breathing. In November and December 1975, he was seen for reported chest pain and another upper respiratory infection. In January 1976, he was treated for mild wheezing associated with an upper respiratory infection. In February 1976, he was seen for treated for reported chest pain, thought to possibly be costochondritis. A report of medical history dated in January 1976 shows a history of pneumonia in September 1974 and a history of shortness of breath and chest pain attributed to chronic bronchitis in January 1976. In June 1976, he was treated for an upper respiratory infection. The evidence of record also included a private medical record from C. L. Bowers, M.D., dated in August 1978, that showed the Veteran had been treated for chest pains, but that chest X-rays had been negative. A VA general medical examination report dated in October 1978 showed the Veteran smoked a pack a day. Expansion was good, but breath sounds were slightly diminished. The examiner concluded that no lung disease was found. As such, the RO in November 1978 denied entitlement to service connection as it was determined that the evidence had not shown a current disability. Evidence added to the record since the final November 1978 RO decision, in pertinent part, includes VA outpatient treatment records dated from 2013 to 2021 showing intermittent treatment for symptoms associated with upper respiratory infection or chest pain. The additional evidence also includes the Veteran’s October 2020 Board testimony during which he asserted that he had not had any respiratory issues prior to his entrance into service. He described having walking bronchitis pneumonia during service in Germany for which he was hospitalized. He added that he continued to experience intermittent symptoms during and ever since active service. He noted that he has been prescribed an inhaler for treatment. The foregoing medical evidence showing ongoing intermittent treatment for respiratory symptoms, coupled with the Veteran’s testimony as to onset and continuity of symptoms since active service, constitutes new and material evidence, as this evidence was not previously of record when the prior decision was made. The additional evidence, taken as a whole, at the very least, triggers VA’s duty to assist by providing a VA examination. Thus, it relates to an unestablished fact necessary to substantiate the claim and is considered new and material. See Shade, supra. As such, the claim is reopened. 2. Whether new and material evidence having been received to reopen the previously denied claim of service connection for bilateral pes planus. The Veteran contends that he has bilateral pes planus that is manifested as a result of his period of active service. The Veteran’s claim of service connection was initially denied by the RO in November 1978. The Veteran did not appeal the decision and did not remit any submissions to the RO which contained new and material evidence pertaining to the claim prior to the expiration of the appellate period. See 38 C.F.R. § 3.156 (b); Bond, 659 F.3d at 1367-8; see also Beraud, 766 F. 3d at 1402. Thus, the November 1978 rating decision with respect to this issue became final. The evidence of record at the time of the November 1978 RO decision included the Veteran’s service treatment records that showed the Veteran was treated intermittently for painful feet. In November 1974, he was treated for reported pain across both feet. There was no history of trauma. He was prescribed metatarsal arch supports. The evidence of record also included the October 1978 VA general medical examination report that showed a diagnosis of pes planus, first to second degree, bilaterally, with hammer toes. X-rays of the feet with weight bearing revealed no apparent abnormality, and no evidence to suggest pes planus. As the X-rays on examination had been negative, the RO in November 1978 denied entitlement to service connection for bilateral pes planus. Evidence added to the record since the final November 1978 RO decision, in pertinent part, includes a VA outpatient treatment record dated in November 2014 showing treatment for possible pes planus; and in May 2016, showing treatment for a history of pain in his feet. A private medical record from J. W. Ellis, M.D., dated in December 2017, shows that the Veteran was said to have a diagnosis of bilateral pes planus. Dr. Ellis indicated that the Veteran had worn combat boots during active service, and that by the end of basic training, he had developed pain in the arches of both feet. He was said to have continued to have pain in the arch of both feet. He had been treated with medication and orthotics. Dr. Ellis opined that it was more likely than not that running in combat boots and prolonged standing and running in the Army caused strains of the muscles, ligaments, and joints of the arch of both feet causing the arches to weaken and fall causing bilateral pes planus. The additional evidence also includes the Veteran’s October 2020 Board testimony during which he asserted that he began having problems with his feet during service when he had been running. He added that he continued to experience intermittent symptoms during and ever since active service. The foregoing medical evidence showing ongoing intermittent treatment for bilateral pes planus and a medical opinion linking the current diagnosis to active service, coupled with the Veteran’s testimony as to onset and continuity of symptoms since active service, constitutes new and material evidence, as this evidence was not previously of record when the prior decision was made. The additional evidence, taken as a whole, relates to an unestablished fact necessary to substantiate the claim and is considered new and material. See Shade, supra. As such, the claim is reopened. 3. Entitlement to service connection for bilateral pes planus. Having reopened the claim of service connection for bilateral pes planus, the Board will now consider the issue directly on the merits. As indicated above, the Veteran contends that he has bilateral pes planus that is manifested as a result of his period of active service. During his October 2020 Board hearing, he testified that he began having problems with his feet during service when he had been running, and that he continued to experience symptoms ever since. Service treatment records show the Veteran was treated intermittently for painful feet, and was prescribed metatarsal arch supports in November 1974. Following service, in October 1978, he was diagnosed with pes planus, first to second degree, bilaterally, with hammer toes, notwithstanding the fact that X-rays were negative. VA outpatient treatment records show a history of pain in his feet. The December 2017 private medical opinion from Dr. Ellis shows a diagnosis of bilateral pes planus. Dr. Ellis indicated that the Veteran had worn combat boots during active service, and that by the end of basic training, he had developed pain in the arches of both feet. He was said to have continued to have pain in the arch of both feet. He had been treated with medication and orthotics. Dr. Ellis opined that it was more likely than not that running in combat boots and prolonged standing and running in the Army caused strains of the muscles, ligaments, and joints of the arch of both feet causing the arches to weaken and fall causing bilateral pes planus. This opinion is considered probative as it was definitive, based upon a complete review of the Veteran's history, and supported by detailed rationale. There is no evidence of record to rebut the opinion in favor of the Veteran’s claim or otherwise diminish its probative weight. In light of the foregoing, the Board finds the evidence to at least be at the very least in relative equipoise as to whether the Veteran’s current bilateral pes planus is manifested as a result of his period of active service. Accordingly, resolving all doubt in favor of the Veteran, service connection for bilateral pes planus is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for obstructive sleep apnea. The Veteran contends that he has developed obstructive sleep apnea that is manifested as a result of his period of active service. During the October 2020 Board hearing, he asserted that he was unable to exercise as a result of his service-connected disabilities, and that his weight gain has resulted in the obstructive sleep apnea. The Veteran’s service treatment records are silent for treatment of or a diagnosis related to obstructive sleep apnea. Following active service, the December 2017 private medical opinion from Dr. Ellis shows that the Veteran was diagnosed with sleep apnea in 2016 and had been prescribed a continuous airway pressure (CPAP) machine. Dr. Ellis opined that it was more likely than not that the service-connected fractured left ankle and low back disabilities had contributed to decreased activities of daily living and decreased ability to exercise, which contributed to weight gain and which had contributed to and aggravated his sleep apnea. This opinion is considered probative as it was definitive, based upon a complete review of the Veteran’s history, and supported by detailed rationale. There is no evidence of record to rebut the opinion in favor of the Veteran’s claim or otherwise diminish its probative weight. As indicated above, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. Service connection has been established for lumbosacral spine strain and arthritis, along with associated left and right lower extremity radiculopathy; and for traumatic arthritis of the left ankle with instability, residual of fracture. In light of the opinion of Dr. Ellis, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current obstructive sleep apnea is secondary to the service-connected low back and left ankle disabilities. In this regard, obesity as an “intermediate step” in a causal chain for service connection can be established on either a causal or aggravation basis. See Walsh v. Wilkie, 32 Vet. App. 300 (2020). There is no negative medical opinion evidence. Although the Board is not required to accept medical authority supporting a claim, VA must provide reasons for rejecting that evidence and, more importantly, must provide a medical basis other than its own unsubstantiated conclusions in support of a determination. Jones v. Principi, 16 Vet. App. 219, 225 (2002), citing Smith v. Brown, 8 Vet. App. 546, 553 (1996) (en banc); Colvin v. Derwinski, 1 Vet. App. 171 (1991). Here, because the only medical opinion evidence supports the Veteran’s claim, service connection for obstructive sleep apnea is warranted. In this regard, the Board points out that the United States Court of Appeals for Veterans Claims (Court) has cautioned against seeking an additional medical opinion where favorable evidence in the record is unrefuted, and indicated that it would not be permissible to undertake further development if the purpose was to obtain evidence against an appellant’s claim. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for obstructive sleep apnea is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for anemia. The Veteran contends that he has a disability manifested by anemia as a result of his period of active service. A review of the Veteran's service treatment records does not demonstrate any findings related to a diagnosis of anemia. Following service, a VA General Medical Examination report dated in October 1978 does not show any relevant symptoms regarding anemia. VA outpatient treatment records dated from 2017 to 2021 show that the Veteran had a history of anemia. In October 2020, it is indicated that the anemia was first diagnosed in 2013. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, or disease. The Board concludes that, while the Veteran has a current diagnosis of anemia, there is no evidence of record that he was treated for anemia during service, and the preponderance of the evidence weighs against finding that the Veteran's diagnosed anemia is otherwise related to an in-service injury or disease. The most probative evidence of record suggests that the anemia began in 2013. There is no evidence to suggest that it was etiologically related to active service, or that it was manifested to a compensable degree within the first post-service year. The Board recognizes the Veteran's contentions that he has anemia that is related to active service. Lay assertions may serve to support a claim for service connection when they relate to the occurrence of events that are observable as a lay person or the presence of a disability or symptoms of a disability that are subject to lay observation. 38 U.S.C. § 1153 (a); 38 C.F.R. § 3.303 (a); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, while the Veteran is competent to describe his experiences, his reports are outweighed by the other evidence of record. Significantly, the Veteran is not competent to provide an opinion as to causation in this case because he does not possess the requisite medical expertise required to opine as to the etiology of his diagnosed anemia. While the Veteran may believe that his anemia is related to active service, the preponderance of the evidence weighs against such finding. Given the evidence against the claim, it would be speculative to conclude that the Veteran's anemia was incurred during active service, and the law provides that service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993). As the preponderance of the evidence is against the claim of service connection, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to service connection for a thyroid disability. The Veteran contends that he has hypothyroidism as a result of his period of active service. During the October 2020 Board hearing, he described that he had been treated for his thyroid disorder at the same time as his bronchitis, at which time he had lost significant weight. A review of the Veteran’s service treatment records does not demonstrate any findings related to a diagnosis of a thyroid disability. Following service, a VA General Medical Examination report dated in October 1978 does not show any relevant symptoms regarding the thyroid. VA outpatient treatment records dated from 2013 to 2021 show that the Veteran had a history of hypothyroidism. It was suggested that the onset had been in 2013. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, or disease. The Board concludes that, while the Veteran has a current diagnosis of hypothyroidism, there is no evidence of record that he was treated for a thyroid disorder during service, and the preponderance of the evidence weighs against finding that the Veteran’s diagnosed hypothyroidism is otherwise related to an in-service injury or disease. The Board recognizes the Veteran’s contentions that he has hypothyroidism that is related to active service. However, while the Veteran is competent to describe his experiences, his reports are outweighed by the other evidence of record. Significantly, the Veteran is not competent to provide an opinion as to causation in this case because he does not possess the requisite medical expertise required to opine as to the etiology of his diagnosed hypothyroidism. While the Veteran may believe that his thyroid disorder is related to active service, the preponderance of the evidence weighs against such finding. Given the evidence against the claim, it would be speculative to conclude that the Veteran’s hypothyroidism was incurred during active service, and the law provides that service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert, 5 Vet. App. at 33. As the preponderance of the evidence is against the claim of service connection, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a lung disability. Having reopened the claim of service connection for a lung disability, additional development is required prior to further adjudication. As indicated above, the Veteran asserts that he has had residuals of in-service pneumonia and bronchitis active service. Service treatment records show that the Veteran was treated on numerous occasions for upper respiratory infection, difficulty breathing, bronchitis, and chest pain. Soon after service, in August 1978, he was seen for reported chest pain. In October 1978, he exhibited diminished breath sounds on VA examination. Post-service VA outpatient treatment records show intermittent treatment for symptoms associated with upper respiratory infection, cough, and chest pain. The Veteran has not had a specific VA respiratory examination to determine the nature and etiology of the Veteran’s asserted lung disability. See McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). As such, the Veteran must be afforded an examination. 2. Entitlement to service connection for a psychiatric disorder, to include PTSD. The Veteran asserts that he has a psychiatric disorder that was first manifested during his period of active service. During his October 2020 Board hearing, he testified that he experienced numerous episodes of anxiety and panic attacks during active service. He added that he had not had such symptoms prior to active service, but that he has continued to experience them ever since service. He noted that he had been assessed with PTSD at a VA outpatient treatment center in May 2013, but, was later told he had not met the criteria for a diagnosis. A review of the Veteran’s service treatment records reveals a report of medical history dated in January 1976 wherein he indicated that he had experienced depression or excessive worry and nervous trouble of any sort. He also indicated that he did not know whether he had ever had frequent trouble sleeping, loss of memory or amnesia, or periods of unconsciousness. Following service, the August 1978 private medical record from Dr. Bowers indicates that the Veteran had been treated for anxiety. VA outpatient treatment records dated from April 2013 show intermittent treatment for symptoms associated with adjustment disorder with depressed mood; depressive disorder, not otherwise specified; PTSD; and unspecified anxiety. In August 2015, February 2017, and March 2017, VA issued a Formal Finding indicating that the Veteran had not provided sufficient information required to corroborate the stressful events to allow for meaningful research of records. While the RO has determined that the Veteran’s asserted stressors could not be verified, the service treatment records do demonstrate that he was experiencing nervous trouble, depression, and excessive worry during service. He was treated for anxiety soon after active service. VA outpatient treatment record demonstrate a history of variously diagnosed psychiatric disorders. The Veteran has not been afforded a specific VA mental disorders examination to determine the nature and etiology of his asserted psychiatric disorder. See McLendon, 20 Vet. App. at 81-82. As such, the Veteran must be afforded an examination. 3. Entitlement to service connection for vertigo. The Veteran asserts that he has a disability manifested by vertigo that was first manifested during his period of active service. During the October 2020 Board hearing, he described that he has been having intermittent symptoms of dizziness ever since active service. Service treatment records show that the Veteran was treated for reported dizziness in October 1974, April 1976, and July 1976. The January 1976 report of medical history shows that the Veteran indicated he had experienced dizziness. Following service, the August 1978 record from Dr. Bowers shows that the Veteran had reported dizziness in June 1978. VA outpatient treatment records dated from 2013 show that the Veteran was treated intermittently for reported dizziness. The Veteran was afforded a VA examination in February 2017 at which time the examiner noted a medical history of a date of onset of symptoms in 2015. The examiner indicated that the Veteran’s balance complaint was at least as likely as not due to his back and foot issues. The examiner added that for the claimed condition of vertigo, there was no diagnosis because there was no pathology to render a diagnosis. Staggering was noted; however, this was a result of his back and foot issues. The February 2017 VA medical opinion is of limited probative value as it is based upon an inaccurate factual premise as it suggests that there is no evidence of treatment in service with onset in 2015, whereas the service treatment records clearly establish in-service treatment for dizziness. Moreover, the VA outpatient treatment records show repeated intermittent complaints of dizziness, an unsteady gait. As such, the issue must be remanded for an additional medical opinion. See Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 4. Entitlement to service connection for residuals of cold weather injury of left upper extremity. 5. Entitlement to service connection for residuals of cold weather injury of right upper extremity. 6. Entitlement to service connection for residuals of cold weather injury of left lower extremity. 7. Entitlement to service connection for residuals of cold weather injury of right lower extremity. The Veteran asserts that he has residuals of cold weather injury of the left and right, upper and lower extremities. During the October 2020 Board hearing, he described that he experienced frostbite during service in Germany when he had fallen asleep in a tank that was not equipped with a heater during extremely cold temperatures. He added that he experienced related symptoms ever since. A review of the Veteran’s service treatment records reveals that in March 1976, he was treated at the Bamberg Aid Station for numbness and tingling following recent duty under very cold conditions. An impression of chilblains was provided. Following service, VA outpatient treatment records show that the Veteran has reported intermittent neurological symptoms of the upper and lower extremities. While some of his symptoms have been attributed to sciatic neuropathy, he has not been afforded a specific VA examination to address whether any reported manifestations are etiologically related to the chilblains in service. See McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). As such, the Veteran must be afforded an examination. 8. Entitlement to a TDIU. In light of the grant of service connection for bilateral pes planus and obstructive sleep apnea, and given the additional development directed herein, a remand is necessary in order for the agency of original jurisdiction to implement the allowances prior to consideration of the TDIU claim, as the awards of service connection may impact outcome of the TDIU claim. Therefore, the claims are inextricably intertwined and, before the issue of entitlement to TDIU can be addressed on appeal, the grant of service connection must be implemented. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the nature and etiology of his asserted lung disability. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the reported pneumonia, bronchitis, chest pain, and upper respiratory infections during active service. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 2. Schedule the Veteran for a psychiatric examination to determine the nature and etiology of his asserted psychiatric disorder, to include PTSD. If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. If the Veteran is diagnosed with a personality disorder and PTSD - The examiner must opine whether the PTSD was at least as likely as not superimposed on a personality disorder during active service and resulted in additional disability. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the January 1976 report of medical history wherein he indicated that he had experienced depression or excessive worry and nervous trouble of any sort. He also indicated that he did not know whether he had ever had frequent trouble sleeping, loss of memory or amnesia, or periods of unconsciousness. Consideration must also be given to the August 1978 private medical record from Dr. Bowers that indicates that the Veteran had been treated for anxiety. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for a particular psychiatric disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 3. Schedule the Veteran for a VA examination for his asserted vertigo. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. The examiner is asked to opine as to whether it is at least as likely as not that the Veteran's asserted vertigo had its onset in service, or is otherwise the result of a disease or injury in service, to specifically include the numerous episodes of dizziness during active service? The examiner is also requested to comment on the ongoing treatment for reported dizziness in the VA outpatient treatment records. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran's reports of symptomatology, he or she must provide a reason for doing so. The absence of evidence of treatment for vertigo in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 4. Schedule the Veteran for an examination to determine the nature and etiology of his asserted residuals of cold weather injury of the left and right, upper and lower extremities. The examiner must opine whether they are at least as likely as not related to an in-service injury, event, or disease, including the diagnosed chilblains following exposure to cold in March 1976. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. 5. Following completion of the above development, readjudicate the TDIU claim. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Orfanoudis, 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.