Citation Nr: 21026143 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 13-25 970 DATE: April 29, 2021 ORDER Entitlement to a rating in excess of 10 percent for patellofemoral pain syndrome with degenerative arthritis of the left knee is denied. Entitlement to service connection for an eye disability other than hypertensive retinopathy, to include amblyopia, sensitivity to light, extreme astigmatism, and corneal arcus, is denied. REMANDED Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for sleep apnea, to include as secondary to service-connected hypertension with headaches, is remanded. FINDINGS OF FACT 1. The Veteran’s patellofemoral pain syndrome with degenerative arthritis of the left knee has not manifested in flexion limited to 45 degrees or less or extension limited to 10 degrees or more, even when considering functional impairment due to factors such as pain, weakness, fatigability, incoordination, or pain on movement. 2. The appellant does not have an eye disability other than hypertensive retinopathy, to include amblyopia, sensitivity to light, extreme astigmatism, and corneal arcus, that originated during service or is otherwise etiologically related to service, to include superimposed over a congenital defect. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for patellofemoral pain syndrome with degenerative arthritis of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5024, 5260, 5261. 2. The criteria for entitlement to service connection for an eye disability other than hypertensive retinopathy, to include amblyopia, sensitivity to light, extreme astigmatism, and corneal arcus, have not been met. 38 U.S.C. §§ 101, 106, 1110, 1111, 1131; 38 C.F.R. §§ 3.303, 4.9. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1998 to September 2001. This matter comes before the Board on appeal from a February 2011 Regional Office (RO) rating decision. In November 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Increased Rating 1. Entitlement to a rating in excess of 10 percent for patellofemoral pain syndrome with degenerative arthritis of the left knee is denied. Disability ratings are determined by comparing a veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. “Staged ratings,” or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See generally DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Joints are to be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if applicable, with the range of the opposite, undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). In the case at hand, the Veteran’s left knee disability has been assigned a 10 percent rating pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5003-5024. This diagnostic code directs that the disability be rated based on limitation of motion. Separate ratings may be assigned for limited knee motion in flexion (under Diagnostic Code 5260) and in extension (under Diagnostic Code 5261), as well as for instability (under Diagnostic Code 5257). VA Gen. Counsel. Prec 23-97 (July 1, 1997). A separate compensable rating may also be assigned for meniscal pathology under Diagnostic Code 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). In the case at hand, the Veteran has neither instability nor meniscal pathology. (See, e.g., June 2019 VA Knee and Lower Leg Conditions examination report.) Therefore, the Board need not discuss whether entitlement to separate ratings is warranted under Diagnostic Codes 5257, 5258, or 5259. The Schedule provides that the normal range of motion of the knee is 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, a 0 percent (noncompensable) rating is assigned for leg flexion limited to 60 degrees. A 10 percent rating is assigned for leg flexion limited to 45 degrees. A 20 percent rating is assigned for leg flexion limited to 30 degrees. A maximum 30 percent rating is assigned for leg flexion limited to 15 degrees. Diagnostic Code 5261 provides a 0 percent rating for leg extension limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating is warranted where extension is limited to 20 degrees. A 40 percent rating is warranted where extension is limited to 30 degrees. A 50 percent rating is warranted where extension is limited to 45 degrees. The Veteran has undergone VA examinations in the case at hand in June 2010, January 2013, May 2016, and June 2019 and obtained an addendum opinion in February 2020. The June 2010 VA examination report notes that the Veteran reported that his knee pain has progressively worsened. It is constant, so there are no flare-ups. Range of motion was from 0 to 120 degrees with end range of pain in flexion with slight guarding of the movement. The Veteran’s gait was slow and he did not use assistive devices. The January 2013 VA examination report notes that the Veteran reported constant infrapatellar aching pain at 6 out of 10 severity. Bending hurts, so the Veteran must sit with his knee straight. He takes over the counter medication. He reported that he has flare-ups when he bends his knee, including when he sits down with his knee bent or steps up. On examination, flexion was to 125 degrees with objective evidence of painful motion beginning at 115 degrees. Extension was to 0 degrees with no objective evidence of painful motion. The Veteran did not lose any range of motion on repetitive use testing. With respect to functional impairment, the Veteran had less movement than normal and pain on movement. The Veteran regularly used knee braces. The May 2016 VA examination report notes that the Veteran’s pain has become sharper since leaving active duty. He also reported that his knee aches and swells. He reported that his pain level is 8 out of 10. His knee is aggravated by weather, high impact, stairs, kneeling, bending twisting, running, walking more than one mile, and sitting more than 30 minutes. It is alleviated by ice, motrin, braces, changing position every 30 minutes, and sitting with his knee extended. He reported that flare-ups occur when he walks in the cold. He denied incapacitation. In terms of functional impairment, he reported that he gets pain, swelling, and difficulty with high impact and weight bearing activities. On examination, flexion was to 120 degrees and extension was to 0 degrees, with pain on flexion. The decreased range of motion did not contribute to functional loss. Pain during the examination was noted on rest and non-movement. There was no evidence of pain with weight bearing. The Veteran was able to perform repetitive use testing, and there was no additional functional loss or range of motion loss. The June 2019 VA examination report notes that the Veteran has reported that his knee disability had worsened since his last VA examination. He reported having frequent crepitus, constant sharp/dull pain, occasional swelling, and stiffness that is aggravated by activities and weather changes. Average pain at rest is 2 out of 10, and sharp pain when moving is 9 out of 10. He takes over-the-counter medications as needed. The Veteran reported that he can no longer run or lift heavy objects due to his knee disability. On examination, flexion was to 120 degrees and extension was to 0 degrees. Pain was noted on flexion and extension and was noted to cause functional loss. There was evidence of pain with weight bearing, but there was no objective evidence of crepitus. There was no additional loss of range of motion on repetitive use. The Veteran’s left knee was not having a flare-up at that time, and the examiner did not provide a basis for being unable to describe impairment during a flare-up. In Sharp, the Court held that the Board may accept a VA examiner’s assertion that he or she cannot offer such an opinion without resort to speculation only after it determines that the examiner’s conclusion is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. It must be clear that such an opinion is not procurable based on a lack of knowledge among the medical community at large and not merely on a lack of expertise, insufficient information, or unprocured testing on the part of the specific examiner. Because there was no estimation of additional loss of range of motion on flare-up, the Board remanded this claim to obtain an addendum opinion. The requested opinion was obtained in February 2020. Following review of the claims file, the examiner opined that pain, weakness, fatigability, or incoordination does not significantly limit functional ability with flare-ups. The examiner was unable to describe this loss in terms of range of motion. The examiner explained that “Following review of the Veteran’s history including subjective complaints, relevant evidence, objective examination findings, and using my clinical judgment and medical expertise, I have identified no basis to offer additional losses of motion or function during a flare up.” The Board finds this final opinion to be highly probative in the case at hand, as it was authored by an examiner who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). The examiner reviewed the lay and medical evidence but found no basis for providing additional losses of motion or function during a flare up. VA does not have to demand an opinion from the examiner. See Jones v. Shinseki, 23 Vet. App. 382, 391 (2010) ("While VA has a duty to assist the Veteran by providing a medical examination in certain situations, that duty does not extend to requiring a VA physician to render an opinion beyond what may reasonably be concluded from the procurable medical evidence."). The Board finds that the above evidence reflects that the Veteran’s flexion was not limited to 45 degrees or less and his extension was not limited to 10 degrees or more, even when considering functional impairment due to factors such as pain, weakness, fatigability, incoordination, or pain on movement at any point during the appeals period. Therefore, entitlement to a rating in excess of 10 percent based on limitation of motion of the right knee was not warranted. Indeed, the Veteran has undergone four VA examinations, all of which consistently show range of motion that does not meet the criteria for a compensable rating, much less the criteria for a zero percent rating under Diagnostic Codes 5260 and 5261. Thus, the Board finds that the Veteran’s complaints of functional loss, including functional limitation during bouts of flare-ups, are adequately compensated by the currently assigned rating, as the February 2020 VA examination report expressly notes that pain, weakness, fatigability, or incoordination does not significantly limit functional ability with flare-ups. In other words, the Veteran’s current 10 percent disability rating reflects that, while he does not meet the criteria for a compensable rating, he does have a painful knee joint. See 38 C.F.R. § 4.59. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. Service Connection 2. Entitlement to service connection for an eye disability other than hypertensive retinopathy, to include amblyopia, sensitivity to light, extreme astigmatism, and corneal arcus, is denied. Service connection is warranted where the evidence of record establishes that an 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 thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Refractive errors of the eyes are congenital or developmental defects and are not diseases or injuries for compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9. Therefore, in general, service connection may not be allowed for refractive error of the eyes, including myopia, presbyopia, and astigmatism, even if visual acuity decreased in service. However, service connection may be granted for refractive error of the eye if there was a superimposed disease or injury that created additional disability. Id. The Veteran testified at his Board hearing that “light sensitivity triggered the headaches” and that he has light sensitivity on a daily basis. (See Board hearing transcript, page 90.) He noted that he mentioned his light sensitivity in service. (See Board hearing transcript, page 91.) The Board notes that the Veteran’s light sensitivity is compensated as part of his service-connected disability, at it is already being contemplated by the migraine headache rating criteria of 38 C.F.R. § 4.124a, Diagnostic Code 8100. See Holmes v. Wilkie, No. 19-2495, 2020 U.S. Vet. App. Claims (November 25, 2020). Therefore, the Board finds that further discussion of the Veteran’s light sensitivity is not necessary. The Veteran’s September 1997 enlistment examination notes that the Veteran’s eyes were clinically normal on enlistment. It notes distant vision in the right eye of 20/70 uncorrected and 20/25 corrected, and near vision in the right eye of 20/40 uncorrected and 20/25 corrected. It notes distant vision in the left eye of 20/100 uncorrected and 20/30 corrected, and near vision in the left eye of 20/40 uncorrected and 20/25 corrected. He denied a history of, or current, eye disorder on his September 1997 enlistment medical history report but reported at that time that he wears glasses. He denied any history of eye trouble, injury, or illness on a medical prescreening form. An October 1998 eye consultation contains the following vision readings without correction: right eye far vision of 20/200 and near vision of 20/100, and left eye far vision of 20/100 and left eye near vision of 20/50. It notes best prescribed correction as follows: right eye far vision of 20/50 and near vision of 20/40, and left eye far vision of 20/50 and left eye near vision of 20/40. A July 1999 service treatment record notes decreased distant vision. Another July 1999 optometry record notes that the Veteran was being fitted for contact lenses. A February 2001 service treatment record contains a notation of “mild amblyopia.” This record notes that the Veteran denied having or having ever had “Eye injuries, disease, surgery,” glaucoma, and cataracts. The Veteran’s July 2001 separation examination report notes a clinical abnormality of the eyes, which it identifies as decreased visual acuity. It notes right eye distant vision of 20/40 and near vision of 20/30. It notes left eye distant vision of 20/30 and near vision of 20/30. (These numbers are presumably the Veteran’s best corrected vision.) He denied a history of, or current, eye disorder on his July 2001 separation medical history report, but he did note that he wears contacts or glasses. The Veteran underwent VA examinations in connection with this claim in May 2016, October 2017, and February 2020. The May 2016 VA eye conditions examination report notes that the Veteran reported having had high astigmatism and that he has worn spectacles since childhood. Based on review of the record and interview and examination of the Veteran, the May 2016 VA examiner, who is an optometrist, diagnosed, in relevant part, corneal arcus with an onset date of 1998. The examiner did not provide an etiology opinion for this diagnosis. With respect to functional impact, the examiner noted that the Veteran’s eye conditions impact his ability to work in that he has visual disturbance/light sensitivity related migraines and that this would impact his ability to operate heavy equipment. The examiner noted that the Veteran’s current occupation was administrative and that he lost 0 to 1 week of work in the last 12 months. The examiner noted that the Veteran has “Visual disturbance and light sensitivity as trigger mechanism[s] for migraine[s]” and “Extreme astigmatism [bilaterally] – congenital, best corrected to 20/30 [bilaterally].” The examiner stated that “There is moderate sign of arteriovenous changes on the retina and corneal arcus due to high cholesterol.” The October 2017 VA eye conditions examination report found that the Veteran’s extreme astigmatism and corneal arcus are less likely than not caused by the claimed in-service injury, event, or illness. In the rationale, the examiner noted that “Extreme astigmatism is congenital, not service related,” and that “Corneal arcus- is not service related, common in general population.” The examiner also determined that visual disturbance and light sensitivity is less likely than not due to or the result of the Veteran’s service-connected headaches, as “Visual disturbance and light sensitivity can often be caused by Migraine.” The examiner also found that the Veteran’s astigmatism is less likely than not aggravated beyond its natural progression by the service-connected condition, as “Astigmatism is entirely congenital.” The examiner also opined that the Veteran’s visual disturbance is not at least as likely as not aggravated beyond its natural progression by his headaches, with the rationale being that “Visual disturbance can be from migraine but there is no definite relation as to its natural progression.” The February 2020 VA examiner opined that the Veteran’s astigmatism is less likely than not due to or the result of service or a service-connected disability, nor was it at least as likely as not aggravated beyond its natural progression by a service connected condition. In his rationale, the examiner noted that “extreme astigmatism is a congenital condition unrelated to service or in service related conditions.” He also noted that “astigmatism being a congenital condition relating to the curvature of the cornea is highly unlikely to be aggravated by in service conditions.” He further noted that “astigmatism being a congenital condition or error in development is highly unlikely to be related to in-service conditions.” Next, he noted that “astigmatism is unrelated to hypertension or migraines.” Finally, he stated that “astigmatism being an inherited corneal curvature would be highly unlikely to be affected by hypertension or migraine headaches.” The examiner also found that the Veteran’s corneal arcus is less likely than not due to or the result of service or a service-connected disability, nor was it at least as likely as not aggravated beyond its natural progression by service connected condition. In his rationale the examiner noted that “A corneal arcus can be due to mostly three factors: heredity, high cholesterol levels, aging. All of these biological factors are not due to work related or service related conditions.” He also stated that “an arcus senilis is most often a sign of aging which tends to be part of a genetic pre-disposition.” He further noted that “an arcus senilis is not due to work related/service related conditions nor is it aggravated by work related conditions.” He also stated that “an arcus senilis is not related to service, it is related to aging and genetic pre-disposition.” He also noted that “an arcus senilis is not related to hypertension or migraines.” In addition, he stated that “an arcus senilis has a 50% probability or less to be related to in-service conditions.” Finally, he noted that “an arcus senilis is not a pathology. It does not affect visual acuities nor do we have a clear starting date as it is a slowly progressive condition. The cornea turns grayish on the periphery as an individual ages, it does not affect vision.” The Board finds that the February 2020 opinion is highly probative to the case with respect to the issues of astigmatism and corneal arcus, as it was authored by an optometrist who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It is based on review of the record and provides a thorough etiology opinion and rationale that discusses the facts of the Veteran’s case and pertinent medical principles. The examiner determined that the Veteran’s astigmatism is a congenital defect and that his corneal arcus is not a pathology and does not affect visual acuities. The Board further notes that, with respect to the astigmatism, the Veteran’s service treatment records reflect that there is no evidence of a superimposed injury in service that created additional disability. The only remaining contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. In short, the Board finds that entitlement to service connection for a diagnosed eye disability is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. REASONS FOR REMAND 1. Entitlement to service connection for a right elbow disability is remanded. The Veteran underwent a VA examination for his right elbow claim in June 2019. In relevant part, the VA examiner opined that the Veteran’s service-connected posttraumatic stress disorder (PTSD) with depressed mood, anxiety, and sleep impairment is a contributing factor to his lateral epicondylitis of the right elbow. Specifically, the examiner stated that “The studies show that mental disorders and obesity are contributing factor[s] resulting in multiple site pain, smoking history, [and] repetitive physical activities [that] contribute to lateral epicondylitis.” (With respect to the other noted factors, the examiner noted that the Veteran “actively works as a data analyst involving repetitive arm, elbow/hands movements.”) In its January 2020 remand, however, the Board noted that the examiner did not provide a basis for this conclusion. Given that the examiner has suggested an etiological link between the Veteran’s right elbow disability and his service-connected psychiatric disability, the Board remanded this claim for an opinion with a rationale. The February 2020 VA examination report found that the right elbow disability is not related to the service-connected psychiatric disability. As a rationale, the examiner noted that “The claimed disorder is a separate entity entirely from the service connected condition and unrelated to it. The medical literature does not support a medical relationship. A nexus has not been established. [A]ny comorbidity between [service-connected disability] and [nonservice-connected] elbow [disability] are mere coincidence…” The examiner also found that the Veteran’s right elbow disability was not at least as likely as not aggravated beyond its natural progression by the service-connected psychiatric disability. As a rationale, the examiner noted that “there is no anatomic or medical connection between [service-connected disability] and [nonservice-connected] claim.” With respect to conflicting medical evidence, the examiner noted that “The elbow is completely separate for a NEXUS which should be a strong negative. [P]rior mention of such earlier appears to be a mistypo at the time on re[-]review.” The Board finds that a remand for an addendum opinion is necessary, as it is unclear which portion of the June 2019 examination report appears to be a typo. A clarification of this statement is required, or, in the alternative, the examiner is requested to evaluate the substance of the June 2019 VA examination report. 2. Entitlement to service connection for sleep apnea, to include as secondary to service-connected hypertension with headaches, is remanded. This claim was previously remanded in January 2020 to obtain an opinion with respect to whether the Veteran’s obesity was caused by his service-connected hypertension with headaches, including medications for treatment. If such a relationship was found, the examiner was asked whether the obesity/weight gain was a substantial factor in causing sleep apnea. If such a relationship was found in response to this second prompt, the examiner was asked whether the sleep apnea would have not occurred but for the obesity/weight gain caused by the service-connected hypertension with headaches, including medications for treatment. Pursuant to the Board’s January 2020 Remand, a thorough VA opinion was provided in February 2020. Unfortunately, the claim must be remanded again to ensure compliance with a United States Court of Appeals for Veterans Claims (Court) precedential opinion that was issued on February 24, 2020, after the Board’s remand. In Walsh v. Wilkie, 32 Vet. App. 300 (2020), the Court held that “the Board clearly erred in relying on a medical opinion that did not adequately address whether the secondary service connection was warranted based on a theory that the veteran’s obesity was aggravated by her service-connected conditions since it focus[ed] on direct causation and was silent on the question of aggravation of obesity.” The Court addressed “G.C. Precedent Opinion 1-2017” (VAOPGCPREC 1-2017), noting that it “does not mention the concept of aggravation in the portion that discusses obesity as an ‘intermediate step’ and references only subsection (a) of 38 C.F.R. § 3.310. Nevertheless, the principles contained in § 3.310 make any distinction in G.C. Opinion 1-2017 between causation and aggravation legally untenable.” Walsh, 32 Vet. App. at 305. The Court maintained that “[d]espite the G.C. opinion’s silence regarding aggravation, the Board, in accordance with § 3.310(b), must consider aggravation in this context when the theory is explicitly raised by the veteran or reasonably raised by the record.” Id. at 307. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran’s records were last obtained. 2. Send the claims file to the examiner who authored the February 2020 VA examination report, or another qualified examiner, to obtain an addendum opinion with respect to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s right elbow disability was caused or aggravated by his service-connected acquired psychiatric disability. In offering this opinion, the examiner should consider the June 2019 VA examination report that opined that the Veteran’s service-connected acquired psychiatric disability is a contributing factor to his lateral epicondylitis of the right elbow. The June 2019 examiner had stated that “The studies show that mental disorders and obesity are contributing factor[s] resulting in multiple site pain, smoking history, [and] repetitive physical activities that contribute to lateral epicondylitis.” The Board had remanded this claim to obtain an opinion that explains a rationale for this opinion. The February 2020 VA examination report found that the right elbow disability is not related to the service-connected psychiatric disability. As a rationale, the examiner noted that “The claimed disorder is a separate entity entirely from the service connected condition and unrelated to it. The medical literature does not support a medical relationship. A nexus has not been established. [A]ny comorbidity between [service-connected disability] and [nonservice-connected] elbow [disability] are mere coincidence…” The examiner also found that the Veteran’s right elbow disability was not at least as likely as not aggravated beyond its natural progression by the service-connected psychiatric disability. As a rationale, the examiner noted that “there is no anatomic or medical connection between [service-connected disability] and [nonservice-connected] claim.” With respect to conflicting medical evidence, the examiner noted that “The elbow is completely separate for a NEXUS which should be a strong negative. [P]rior mention of such earlier appears to be a mistypo at the time on re[-]review.” It is unclear which portion of the June 2019 opinion the February 2020 VA examiner was referring to as a typo. The examiner is asked to clarify this statement, or, in the alternative, the examiner is requested to evaluate the substance of the June 2019 VA examination report. 3. Return the February 2020 VA examination report to the author of that opinion, or another qualified examiner, for an addendum opinion that addresses AGGRAVATION. In regard to the findings and conclusions set forth in the February 2020 opinion, does the same apply for aggravation? In other words, the examiner is asked to opine on the following: (a) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s service-connected hypertension with headaches, including medications for treatment, AGGRAVATED the Veteran’s weight gain/obesity? (b) If so, is it at least as likely as not that the AGGRAVATION of weight gain/obesity as a result of service-connected hypertension with headaches, including medications for treatment, was a substantial factor in causing obstructive sleep apnea? (c) If so, is it at least as likely as not that the obstructive sleep apnea would not have occurred but for weight gain/obesity AGGRAVATED by the service-connected hypertension with headaches, including medications for treatment? TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Elizabeth Jalley, 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.