Citation Nr: 21025585 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 19-26 295A DATE: April 28, 2021 ORDER The application to reopen the claim for service connection for narcolepsy is granted. The application to reopen the claim for service connection for a back disability is granted. The application to reopen the claim for service connection for hypertension is granted. The application to reopen the claim for service connection for a right leg disability is granted. The application to reopen the claim for service connection for a left leg disability is granted. Entitlement to service connection for other specified trauma and stressor related disorder is granted. REMANDED Entitlement to service connection for hypertension to include as secondary to traumatic brain injury (TBI) and service-connected disease or injury is remanded. Entitlement to service connection for a right leg disability to include as secondary to a back disability is remanded. Entitlement to service connection for a left leg disability to include as secondary to a back disability is remanded. Entitlement to service connection for narcolepsy to include as secondary to cervical spine disability and TBI is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for TBI is remanded. Entitlement to service connection for sleep apnea to include as secondary to TBI and service-connected disease or injury is remanded. FINDINGS OF FACT 1. In an unappealed November 1957 rating decision, the RO denied entitlement to service connection for sleeping sickness (also classified as narcolepsy), and in an unappealed May 2011 rating decision, the RO determined that new and material evidence was not received to reopen the previously denied claim. 2. The evidence received since the May 2011 rating decision, by itself or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for narcolepsy. 3. In an unappealed November 1957 rating decision, the RO denied the Veteran’s claim of entitlement to service connection for a back disability, and in an unappealed May 2011 rating decision, the RO determined that new and material evidence was not received to reopen the previously denied claim. 4. The evidence received since the May 2011 rating decision, by itself or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for a back disability. 5. In an unappealed May 2011 rating decision, the RO denied the Veteran’s claim of entitlement to service connection for hypertension. 6. The evidence received since the May 2011 rating decision, by itself or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for hypertension. 7. In an unappealed May 2011 rating decision, the RO denied the Veteran’s claim of entitlement to service connection for a right leg disability, not specified. 8. The evidence received since the May 2011 rating decision, by itself or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for a right leg disability, not specified. 9. In an unappealed May 2011 rating decision, the RO denied the Veteran’s claim of entitlement to service connection for a left leg disability, not specified. 10. The evidence received since the May 2011 rating decision, by itself or in conjunction with previously considered evidence, relates to an unestablished fact necessary to substantiate the claim for service connection for a left leg disability, not specified. 11. Clear and unmistakable evidence shows that the Veteran had other specified trauma and stressor related disorder prior to active duty. 12. The Veteran’s other specified trauma and stressor related disorder was aggravated during active duty. CONCLUSIONS OF LAW 1. The May 2011 rating decision that determined new and material evidence was not received to reopen a previously denied claim of service connection for sleeping sickness (also classified as narcolepsy) is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2020). 2. Since the May 2011 rating decision, new and material evidence has been received with respect to the Veteran’s claim of entitlement to service connection for narcolepsy; therefore, the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2020). 3. The May 2011 rating decision that determined new and material evidence was not received to reopen a previously denied claim of service connection for a back disability is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2020). 4. Since the May 2011 rating decision, new and material evidence has been received with respect to the Veteran’s claim of entitlement to service connection for a back disability; therefore, the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2020). 5. The May 2011 rating decision denying service connection for hypertension is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2020). 6. Since the May 2011 rating decision, new and material evidence has been received with respect to the Veteran’s claim of entitlement to service connection for hypertension; therefore, the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2020). 7. The May 2011 rating decision denying service connection for a right leg disability, not specified is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2020). 8. Since the May 2011 rating decision, new and material evidence has been received with respect to the Veteran’s claim of entitlement to service connection for a right leg disability, not specified; therefore, the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2020). 9. The May 2011 rating decision denying service connection for a left leg disability, not specified is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 20.302, 20.1103 (2020). 10. Since the May 2011 rating decision, new and material evidence has been received with respect to the Veteran’s claim of entitlement to service connection for a left leg disability, not specified; therefore, the claim is reopened. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2020). 11. Other specified trauma and stressor related disorder was aggravated by service. 38 U.S.C. §§ 1101, 1111, 1153 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1956 to May 1957. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a November 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). With regard to the Veteran’s claim of service connection for an acquired psychiatric disorder, the Board acknowledges that the United States Court of Appeals for Veterans Claims (Court) has held that the scope of a mental health disability claim includes any psychiatric disability that may reasonably be encompassed by a veteran’s description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In light of the Court’s holding in Clemons, the Board has characterized the claim on appeal as entitlement to service connection for an acquired psychiatric disorder, to include PTSD. New and Material Evidence Pertinent legal criteria In general, rating decisions that are not timely appealed are final. See 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. §§ 20.1100, 20.1103 (2020). Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured to that claim. “New” evidence means evidence not previously submitted to the agency decision-maker. “Material” evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. See 38 C.F.R. § 3.156(a) (2020). The threshold for determining if there is new and material evidence is low. See Shade v. Shinseki, 24 Vet. App. 110 (2010). In the determination of whether new and material evidence has been received, the credibility of the evidence is to be presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The VA is not, however, bound to consider credible that which is the patently incredible. See Duran v. Brown, 7 Vet. App. 216 (1994). Applications to reopen narcolepsy, back disability, right leg disability, left leg disability, and hypertension The RO denied service connection for sleeping sickness (also classified as narcolepsy) in an unappealed November 1957 rating decision on the basis that the Veteran had a history of the condition several months prior to service and there was an absence of any disease or trauma in service. The RO also denied service connection for a back disability in an unappealed November 1957 rating decision on the basis that the Veteran gave a history of a back injury prior to service and there was no evidence of injury to the back in service. The November 1957 rating decision is final. In a May 2011 rating decision, the RO determined that new and material evidence was not received to reopen the previously denied claims of service connection for narcolepsy and a back disability. Also, in the May 2011 rating decision, the RO denied service connection for hypertension and right and left leg disabilities, not specified, on the basis that there was no evidence of a relationship between the Veteran’s hypertension and right and left leg disabilities and service. The Veteran did not file a notice of disagreement to the May 2011 rating decision and new and material evidence was not received within one year of the rating decision. The May 2011 rating decision is therefore final. At the time of the prior final rating decision in May 2011, the record in pertinent part included the Veteran’s service treatment records as well as postservice medical records. A January 1957 service treatment record noted the Veteran was hospitalized for investigation of his tendency to fall asleep. At the time of admission to the hospital, the Veteran reported that he was in good health until May 1956 at which time he began to notice episodes of uncontrollable urges to sleep. He was diagnosed with narcolepsy and release from service primarily for that condition, with the service department noting that the narcolepsy was neither incurred nor aggravated by service. Also, a November 1956 service treatment record noted the Veteran’s complaint of upper back pain that had been bothering him since basic training. He also complained of back pain in August 1956 and December 1956 and was found to have a muscle spasm. The Veteran also reported that he was stabbed in the back prior to service. Additionally, the Veteran complained of leg cramps on his April 1957 report of medical history prior to separation from service. The remainder of service treatment records is absent complaints of or treatment for narcolepsy, a back disability, and a leg disability. The service treatment records were absent complaints of or treatment for hypertension or symptoms associated therewith. Postservice medical records documented treatment for arthritis in the back, hypertension, and sciatica as well as mild bilateral patellofemoral degenerative changes. See VA treatment records dated October 2010 and November 2010. As the May 2011 rating decision is final, new and material evidence is therefore required to reopen the claims. In reviewing the evidence added to the claims folder since the May 2011 denials, the Board finds that additional evidence has been submitted which is sufficient to reopen the Veteran’s narcolepsy, back disability, right leg disability, left leg disability, and hypertension claims. Specifically, the Veteran now contends that the back, right leg, and left leg disabilities are related to an in-service personal assault and that the hypertension and narcolepsy are related to a TBI incurred from the personal assault. See the Veteran’s September 2019 VA Form 9. As indicated above, the Veteran’s previous claims were denied in part because there was no evidence of an in-service injury that caused or aggravated the Veteran’s narcolepsy, back disability, right leg disability, left leg disability, and hypertension. As the new evidence potentially indicates evidence of such, the Board finds that the new evidence relates to an unestablished fact necessary to substantiate the claim. As new and material evidence has been received, the claims for service connection for narcolepsy, a back disability, a right leg disability, a left leg disability, and hypertension are reopened. Service Connection Acquired psychiatric disorder Veterans are entitled to compensation from VA if they develop a disability “resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty.” 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). To establish a right to compensation for a present disability, a veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”-the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has distinguished between those cases in which the preexisting condition is noted upon entry into service, and those cases in which the preexistence of the condition must otherwise be established. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012); see also 38 U.S.C. § 1111 (presumption of sound condition). In a case where there is no preexisting condition noted upon entry into service, a veteran is presumed to have entered service in sound condition, and the burden falls to the government to demonstrate by clear and unmistakable evidence that (1) the condition preexisted service and (2) the preexisting condition was not aggravated by service. Horn, 25 Vet. App. at 234. The government may show a lack of aggravation by establishing by clear and unmistakable evidence “that there was no increase in disability during service or that any ‘increase in disability [was] due to the natural progress of the’ preexisting condition.” Wagner, 370 F.3d at 1096; see also, 38 U.S.C. § 1153; 38 C.F.R. § 3.306. This burden of proof must be met by “affirmative evidence” demonstrating that there was no aggravation. The burden is not met by finding “that the record contains insufficient evidence of aggravation.” Horn, 25 Vet. App. at 236-37. “Clear and unmistakable evidence” is an “onerous” evidentiary standard, requiring that the preexistence of a condition and the no-aggravation result be “undebatable.” Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (noting that clear and undebatable means that the evidence cannot be misinterpreted or misunderstood). With regard to the existence of a preexisting condition, to be “noted” within the meaning of the presumption of soundness statute, the condition must be recorded in the entrance examination report. 38 C.F.R. § 3.304(b); 38 U.S.C. § 1111; Crowe v. Brown, 7 Vet. App. 238, 245 (1994). With regard to PTSD, establishing service connection for it requires (1) medical evidence diagnosing PTSD in accordance with 38 C.F.R. § 4.125(a); (2) a link between a veteran’s present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor occurred. See 38 C.F.R. § 3.304(f) (2020); Cohen v. Brown, 10 Vet. App. 128, 139 (1997). If the Veteran did not engage in combat with the enemy, or the Veteran did engage in combat but the alleged in-service stressor is not combat related, the Veteran’s lay testimony, by itself, is not sufficient to establish the occurrence of the alleged in-service stressor. Instead, the record must contain credible supporting evidence which corroborates the Veteran’s testimony or statements. Moreau v. Brown, 9 Vet. App. 389, 395 (1996). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of the claimed in-service stressors. See Moreau, 9 Vet. App. at 395-396; see also Cohen, 10 Vet. App. at 142. The Veteran contends that he has an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) that is related to service, in particular from an assault when he fought with another service member. See, e.g., an April 2018 VA examination report. The Board acknowledges that the Veteran’s available service treatment and personnel records are absent any finding of a personal assault. However, the Board notes that the Veteran is competent to report the in-service assault and further finds him credible as to this report. In this regard, a VA examiner concluded in an April 2018 report that the Veteran currently has other specified trauma and stressor related disorder and that the disorder was “solidified” during service based on the Veteran’s reported personal assault. Notably, the examiner found the Veteran statements as to the personal assault were consistent based on his review of the treatment records to include the Veteran’s April 1957 report of medical history wherein the Veteran reported depression, nightmares, trouble sleeping, headache, and dizziness. The examiner further noted that such symptoms were not reported on the Veteran’s July 1956 enlistment examination. Therefore, based on these in-service findings and the April 2018 VA examination report, the Board finds that the Veteran is credible as to his reported in-service personal assault. The Board observes that the Veteran’s July 1956 enlistment examination documents a normal psychiatric evaluation and the Veteran denied any mental health symptoms on his report of medical history upon enlistment. Therefore, he is presumed sound upon entrance. Nevertheless, there is clear and unmistakable evidence showing that the Veteran had an acquired psychiatric disorder, specifically other specified trauma and stressor related disorder, that preexisted his active service. The Court of Appeals for Veteran Claims (Court) has held that the presumption of soundness can be rebutted by clear and unmistakable evidence consisting of a Veteran’s own admission of a pre-service history of medical problems. Doran v. Brown, 6 Vet. App. 283, 286 (1994). In the instant case, the April 2018 VA examiner concluded that the Veteran’s other specified trauma and stressor related disorder was precipitated by childhood experiences. The examiner’s rationale for his finding was based on examination of the Veteran and consideration of the Veteran’s medical history. There is no medical opinion contrary to the VA examiner’s opinion as to whether the Veteran’s other specified trauma and stressor related disorder preexisted his active service. Thus, the Board finds that the aforementioned evidence constitutes clear and unmistakable evidence showing that the Veteran’s other specified trauma and stressor related disorder existed prior to active service. The remaining question is whether the pre-existing condition was aggravated by service. The burden is on VA to rebut by clear and unmistakable evidence that the preexisting disability was not aggravated by service. The Board has evaluated the evidence and finds that the competent and probative evidence demonstrates that the Veteran’s current other specified trauma and stressor related disorder was aggravated during service. A competent and probative medical opinion is of record concerning the issue of aggravation for this acquired psychiatric disorder in the form of an April 2018 VA medical opinion. Specifically, the VA examiner concluded after examination of the Veteran and consideration of his medical history that the Veteran’s preexisting other specified and stressor related disorder was aggravated by service, in particular the Veteran’s reported personal assault. The examiner’s rationale for his conclusion was based on his examination of the Veteran to include a trauma checklist as well as consideration of the Veteran’s medical history. The examiner in particular noted that the Veteran’s other specified trauma and stressor related disorder was “solidified” during service as “significant” differences were noted on the Veteran’s report of medical history in conjunction with his separation examination in comparison to the report of medical history in conjunction with the enlistment examination. In this regard, the Board notes that the Veteran reported depression, nightmares, trouble sleeping, headache, and dizziness on his April 1957 report of medical history in conjunction with the separation examination whereas the July 1956 report of medical history examination in conjunction with the enlistment examination was absent such findings. The opinion of the VA examiner was based upon a thorough analysis of the Veteran’s history and current medical condition. See Bloom v. West, 12 Vet. App. 185, 187 (1999) [the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”]. It is not contradicted by the record. Therefore, the Board finds it to be highly probative on the question at issue. Based on the total record, the Board finds that there is sufficient competent evidence to indicate that the Veteran has preexisting other specified trauma and stressor related disorder that was aggravated by service. In summary, the Veteran has met all requirements needed to establish service connection for other specified trauma and stressor related disorder (claimed as PTSD). The benefit sought on appeal is therefore granted. The Board also notes that the evidence of record establishes that the Veteran does not have PTSD. In this regard, the Veteran was afforded a VA examination in April 2018. After examination of the Veteran and consideration of his medical history, the VA examiner concluded that the Veteran does not have PTSD. Specifically, the VA examiner reported that the Veteran did not meet Criterion A or I for a diagnosis of PTSD. In this case, the Board finds that the most probative evidence weighs against finding that the criteria have been met for PTSD. In this regard, the Board finds it highly probative that the VA examiner opined that the Veteran does not have PTSD based upon thorough examination. Moreover, no medical professional has determined that the Veteran currently has PTSD. The Board has considered the Veteran’s statements that he has PTSD. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In addition, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)); Kahana v. Shinseki, 24 Vet. App. 428, 433, n.4 (2011). However, competence must be distinguished from probative weight. Although the Veteran is competent to relate what he experiences through the senses, the lay evidence is lacking in detail to support the conclusion that there is current PTSD. The Veteran’s lay assertions are therefore afforded less probative weight, and less credibility than the VA examination report. Accordingly, the Board finds that service connection for PTSD is not warranted. REASONS FOR REMAND Service connection for narcolepsy, back disability, right leg disability, left leg disability, hypertension, TBI, and sleep apnea With regard to the Veteran’s claim of service connection for a back disability, the Veteran contends that he has a back disability that is related to service, in particular from a personal assault. See the Veteran’s September 2019 VA Form 9. As discussed above, a November 1956 service treatment record noted the Veteran’s complaint of upper back pain that had been bothering him since basic training. He also complained of back pain in August 1956 and December 1956 and was found to have a muscle spasm. The Veteran also reported that he was stabbed in the back prior to service, although his July 1956 enlistment examination revealed a normal back examination. The Board further notes that the Veteran has indicated back pain since service and is currently treated for arthritis in the back. There is no medical opinion of record as to whether the Veteran’s current back disability is related to service. In light of the foregoing, the Board finds that an opinion for such should be obtained on remand. As to the Veteran’s claims of service connection for right and left leg disabilities, the Veteran contends that he has right and left leg disabilities that are related to service, to include the reported personal assault, or are alternatively secondary to his back disability. Id. The Board notes that in April 2018, a VA medical opinion was obtained as to whether the Veteran had right and left leg disabilities that were related to service on a direct basis. However, the Board finds that the Veteran’s right and left leg disability claims are inextricably intertwined with his claim of service connection for a back disability. In other words, development of the back disability claim may impact his right and left leg disabilities claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) [two or more issues are inextricably intertwined if one claim could have significant impact on the other]. The Board further notes that if, and only if, it is determined that the Veteran’s back disability is service connected, then a medical opinion should be obtained as to whether the Veteran has a right and/or left leg disability that is caused or aggravated by the back disability. With respect to the Veteran’s claim of service connection for TBI, the Veteran contends that he has residuals of a TBI related to service, in particular the aforementioned personal assault. There is no medical opinion of record as to whether the Veteran has residuals of a TBI that is related to the in-service personal assault. As the Veteran is competent to report current residuals such as a headache and was assaulted in service and reported headache and dizziness on his April 1957 report of medical history in conjunction with his separation examination, the Board finds that a medical opinion should be obtained on remand as to whether the Veteran has residuals of a TBI related to service. With regard to the Veteran’s claim of service connection for narcolepsy, the Veteran contends that he has narcolepsy that is related to service or is alternatively secondary to a cervical spine disability and TBI. See the Veteran’s September 2019 VA Form 9. As discussed above, the Board is remanding the Veteran’s TBI claim for evidentiary development. Therefore, the Board finds that the Veteran’s narcolepsy claim is inextricably intertwined with his claim of service connection for TBI. In other words, development of the TBI claim may impact his narcolepsy claim. See Harris, supra. The Board further notes that if, and only if, it is determined that the Veteran’s TBI is service connected, then a medical opinion should be obtained as to whether the Veteran has narcolepsy that is caused or aggravated by the TBI. With respect to the Veteran’s claims of service connection for hypertension and sleep apnea, the Veteran contends that he has hypertension and sleep apnea that are related to service or are alternatively secondary to his TBI and service-connected other specified trauma and stressor related disorder. See the Veteran’s September 2019 VA Form 9. The Board notes that there is no medical opinion of record as to whether the Veteran’s hypertension and sleep apnea are caused or aggravated by the service-connected other specified trauma and stressor related disorder. As the Veteran is currently treated for hypertension and sleep apnea, the Board finds that medical opinions should be obtained on remand as to whether the Veteran’s hypertension and sleep apnea are caused or aggravated by the service-connected other specified trauma and stressor related disorder. Further, if, and only if, the Veteran’s TBI is service connected, then a medical opinion should also be obtained as to whether the Veteran’s hypertension and sleep apnea are caused or aggravated by the TBI. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the likely etiology of his back disability and right and left leg disabilities. Based on the review and the examination, the examiner should render an opinion as to the following: a. Whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran has a back disability that was incurred in or aggravated by service, to include his report of a personal assault and treatment for back pain in August 1956, November 1956 and December 1956. b. If, and only if, it is determined that the Veteran’s back disability is service connected, then an opinion should be obtained as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran has a right leg disability that is caused or aggravated by his back disability. If the examiner finds that the right leg disability is aggravated by the back disability, then he/she should quantify the degree of aggravation, if possible. c. If, and only if, it is determined that the Veteran’s back disability is service connected, then an opinion should be obtained as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran has a left leg disability that is caused or aggravated by his back disability. If the examiner finds that the left leg disability is aggravated by the back disability, then he/she should quantify the degree of aggravation, if possible. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached should be provided. 2. Schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the likely etiology of his TBI. Based on the review and the examination, the examiner should render an opinion as to the following: a. Whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran has residuals of a TBI that were incurred in or aggravated by service, to include his report of a personal assault and report of headaches in April 1957. b. If, and only if, it is determined that the Veteran’s TBI is service connected, then an opinion should be obtained as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran has narcolepsy that is caused or aggravated by his TBI. If the examiner finds that the narcolepsy is aggravated by the TBI, then he/she should quantify the degree of aggravation, if possible. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached should be provided. 3. Schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the likely etiology of his hypertension. Based on the review and the examination, the examiner should render an opinion as to the following: a. Whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran has hypertension that is caused or aggravated by his service-connected other specified trauma and stressor related disorder. If the examiner finds that the hypertension is aggravated by the other specified trauma and stressor related disorder, then he/she should quantify the degree of aggravation, if possible. b. If, and only if, it is determined that the Veteran’s TBI is service connected, then an opinion should be obtained as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran has hypertension that is caused or aggravated by his TBI. If the examiner finds that the hypertension is aggravated by the TBI, then he/she should quantify the degree of aggravation, if possible. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached should be provided. 4. Schedule the Veteran for a VA examination by an appropriately qualified examiner to determine the likely etiology of his sleep apnea. Based on the review and the examination, the examiner should render an opinion as to the following:   a. Whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran has sleep apnea that is caused or aggravated by his service-connected other specified trauma and stressor related disorder. If the examiner finds that the sleep apnea is aggravated by the other specified trauma and stressor related disorder, then he/she should quantify the degree of aggravation, if possible. b. If, and only if, it is determined that the Veteran’s TBI is service connected, then an opinion should be obtained as to whether it is at least as likely as not (i.e., a probability of 50 percent or greater) that the Veteran has sleep apnea that is caused or aggravated by his TBI. If the examiner finds that the sleep apnea is aggravated by the TBI, then he/she should quantify the degree of aggravation, if possible. All opinions provided must be thoroughly explained, and an adequate rationale for any conclusions reached should be provided. 5. Review the claims file to ensure that all of the foregoing requested development is completed, and   arrange for any additional development indicated. Then readjudicate the claims on appeal. If the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his attorney with the requisite period of time to respond. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Arif Syed, 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.