Citation Nr: 21026246 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 17-31 796 DATE: April 30, 2021 ORDER The claim of entitlement to service connection for skin cancer is reopened. Entitlement to service connection for diabetes mellitus is granted. Entitlement to service connection for peripheral neuropathy of the left lower extremity as secondary to diabetes mellitus is granted. Entitlement to service connection for peripheral neuropathy of the right lower extremity as secondary to diabetes mellitus is granted. Entitlement to service connection for peripheral neuropathy of the left upper extremity as secondary to diabetes mellitus is granted. Entitlement to service connection for peripheral neuropathy of the right upper extremity as secondary to diabetes mellitus is granted. Entitlement to service connection for actinic keratoses with early basal cell changes/hyperpigmentation of basal layer keratinocytes is granted. Entitlement to an effective date prior to November 9, 2016 for the grant of service-connection for right bicep strain is denied. REMANDED Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD) and/or ischemic heart disease is remanded. Entitlement to service connection for right medial epicondylitis, to include as secondary to service-connected right bicep strain, is remanded. FINDINGS OF FACT 1. A December 2013 rating decision denied entitlement to service connection for skin cancer and a right shoulder disorder. The Veteran did not appeal that decision or submit new or material evidence within one year. 2. The evidence received since the December 2013 rating decision is new and related to previously unestablished facts necessary to substantiate the claim of entitlement to service connection for a skin disorder. 3. The Veteran is presumed exposed to herbicides and diabetes mellitus has been diagnosed during the appeal period. 4. Peripheral neuropathy of the left lower extremity is at least as likely as not due to the service-connected diabetes mellitus. 5. Peripheral neuropathy right lower extremity is at least as likely as not due to the service-connected diabetes mellitus. 6. Peripheral neuropathy of the left upper extremity is at least as likely as not due to the service-connected diabetes mellitus. 7. Peripheral neuropathy of the right upper extremity is at least as likely as not due to the service-connected diabetes mellitus. 8. Actinic keratoses with early basal cell changes are at least as likely as not due to excessive sun exposure during the Veteran’s period of service. 9. VA received the Veteran’s claim for service connection for a right bicep condition on November 9, 2016. CONCLUSIONS OF LAW 1. The December 2013 rating decision denying service connection for skin cancer and a right shoulder condition is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.156(b), 20.302, 20.1103. 2. New and material evidence has been received to warrant reopening of the claim of service connection for a skin disorder. 38 U.S.C. §§ 5107, 5108 (2012); 38 C.F.R. § 3.156. 3. The criteria for service connection for diabetes mellitus due to herbicide exposure are met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for peripheral neuropathy of the left lower extremity as secondary to diabetes mellitus are met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116 (2012); 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for peripheral neuropathy right lower extremity as secondary to diabetes mellitus are met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116 (2012); 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for service connection for peripheral neuropathy of the left upper extremity as secondary to diabetes mellitus are met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116 (2012); 38 C.F.R. §§ 3.102, 3.310. 7. The criteria for service connection for peripheral neuropathy of the right upper extremity as secondary to diabetes mellitus are met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116 (2012); 38 C.F.R. §§ 3.102, 3.310. 8. The criteria for service connection for actinic keratoses and early basal cell changes are met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1116 (2012); 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for an effective date prior to November 9, 2016 for the grant of service-connection for right bicep strain are not met. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably on active duty in the U.S. Army from March 1968 to March 1970. For his service, the Veteran is in receipt of several decorations, including the Vietnam Service Medal with 2 Bronze Service Stars, the Vietnam Campaign Medal with 60 Device, and the Combat Infantryman Badge, among others. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from September 2016 and June 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran did not appeal the September 2016 denial of his claim to reopen the previously denied claim of entitlement to service connection for skin cancer, but he submitted new and material evidence within one year of that decision so it did not become final. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in December 2020 and a transcript of the proceeding is of record. New and Material Evidence and Service Connection In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. 38 U.S.C. §§ 7104, 7105 (2012); 38 C.F.R. §§ 3.104, 20.1100, 20.1103. A finally disallowed claim, however, may be reopened when new and material evidence is presented or secured with respect to that claim. 38 U.S.C. § 5108 (2012). Regardless of the action taken by the RO, the Board must determine whether new and material evidence has been received subsequent to an unappealed RO denial. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). As part of this review, the Board considers evidence of record at the time of the previous final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim, and evidence submitted since a prior final disallowance. Evans v. Brown, 9 Vet. App. 273, 285-86 (1996). New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing 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. 38 C.F.R. § 3.156. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Additionally, new and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). To establish service connection, 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). A Veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed to an herbicide agent unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a)(6)(iii). The Vietnam era is the period beginning on February 28, 1961 and ending on May 7, 1975 for veterans who served in the Republic of Vietnam. For veterans presumed to have been exposed to herbicides, certain enumerated diseases shall be service connected even though there is no record of such disease during service, so long as the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, and the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The enumerated diseases which are deemed to be associated with herbicide exposure include diabetes mellitus. 38 C.F.R. § 3.309(e). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310 (2018); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran is in receipt of a Combat Infantryman Badge and his military occupational specialty was light weapons infantryman. As such, the Veteran is entitled to the combat presumption, which provides that if a veteran engaged in combat with the enemy, his or her lay reports will be sufficient to establish the occurrence of an event or injury during combat as long as such reports are consistent with the circumstances, conditions, or hardships of such service. This is true even if there is no official record of the reported incident unless there is clear and convincing evidence to the contrary. 38 U.S.C. § 1154 (b); 38 C.F.R. § 3.304 (d). This presumption also extends to a combat veteran’s reports of experiencing a permanent disability beginning at the time of injury during combat. Reeves v Shinseki, 682 F.3d 988, 998-1000 (Fed. Cir. 2012). 1. Whether new and material evidence has been received sufficient to reopen the previously denied claim of entitlement to service connection for skin cancer. In a December 2013 rating decision, the RO denied service connection for skin cancer on the grounds that the evidence did not show the Veteran had skin cancer in service or a current diagnosis of skin cancer. The Veteran did not appeal that decision or submit new and material evidence within one year. Thus, the December 2013 rating decision is final. See 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. The evidence of record at the time of the December 2013 decision included the Veteran’s service treatment records (STRs), his claim for benefits, and unrelated VA examination reports. The available evidence did not include a diagnosis of skin cancer. A September 2016 rating decision denied the Veteran’s claim to reopen the previously denied claim of entitlement to service connection for skin cancer on the basis that no new or material evidence had been presented. In November 2016, within a year of the September 2016 rating decision, the Veteran submitted a private medical opinion from Dr. JE. Dr. JE diagnosed actinic keratosis and early basal cell changes and opined the Veteran’s in-service sun exposure caused his currently diagnosed skin conditions. The November 2016 medical opinion constitutes new and material evidence because it was not of record at the time of the December 2013 or September 2016 rating decisions, and the evidence relates to unestablished facts necessary to substantiate the claim. Specifically, the November 2016 opinion shows an etiological relationship between currently diagnosed skin disorders and the Veteran’s period of service. In sum, new and material evidence has been received and the Veteran’s claim is reopened. 2. Entitlement to service connection for diabetes mellitus, to include as due to herbicide exposure. The Veteran served on the landmass of Vietnam from August 1968 to August 1969 and he is presumed exposed to herbicides. See DD 214. The remaining question is whether diabetes mellitus has been diagnosed during the appeal period. The evidence demonstrates the Veteran is diagnosed with diabetes mellitus during the appeal period. A May 2011 record from the Veteran’s private physician includes multiple fasting blood sugar readings and the physician’s assessment of diet controlled type II diabetes mellitus. A September 2014 private disability benefits questionnaire completed by the Veteran’s private physician also notes a current diagnosis of diabetes mellitus type II. A May 2017 VA treatment record includes an impression of diabetes mellitus and the Veteran was prescribed insulin. Thus, the evidence demonstrates that diabetes mellitus type II has been diagnosed during the appeal period and is presumed related to the conceded in-service herbicide exposure. Accordingly, the claim is granted. 3. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as secondary to diabetes mellitus. 4. Entitlement to service connection for peripheral neuropathy right lower extremity, to include as secondary to diabetes mellitus. 5. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to diabetes mellitus. 6. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to diabetes mellitus. The Veteran seeks entitlement to service connection for peripheral neuropathy of all extremities, which he asserts is secondary to diabetes mellitus. See June 2016 claim. First, peripheral neuropathy has been diagnosed during the appeal period. See July 2016 VA examination report; see May 2017 VA treatment note. Second, the peripheral neuropathy is at least as likely as not due to diabetes mellitus. In July 2016, a VA examiner reported the Veteran did not have a diagnosis of diabetes mellitus, therefore the diagnosed peripheral neuropathy of the upper and lower extremities was not due to diabetes mellitus. The examiner did not address the medical evidence of a diagnosis of diabetes mellitus and their opinion is not adequate or afforded probative weight. In November 2016, Dr. JE examined the Veteran and diagnosed peripheral neuropathy of the upper and lower extremities. Dr. JE opined that the neuropathy was due to diabetes mellitus. Dr. JE also noted the presence of cervical spine nerve impingement in the upper extremities and L5-S1 spinal nerve impingement down both legs, but explained the Veteran also had distinct peripheral neuropathy associated with diabetes mellitus. Dr. JE based his conclusion on objective examination of the Veteran and although Dr. JE did not cite review of other medical evidence, Dr. JE is a medical professional competent to diagnose peripheral neuropathy. Further, Dr. JE’s findings are consistent with other available medical evidence, including the VA examination report noting the presence of peripheral neuropathy and a May 2017 VA treatment note reporting the Veteran had neuropathy of many possible etiologies. As Dr. JE’s opinion is consistent with the record and based on interview and examination of the Veteran, the opinion is afforded probative weight. Here, the evidence establishes a diagnosis of peripheral neuropathy of all extremities and diabetes mellitus is service-connected. The preponderance of the evidence establishes the peripheral neuropathy of the upper and lower extremities is at least as likely as not secondary to the service-connected diabetes mellitus and the Veteran’s claims for service connection for peripheral neuropathy of the extremities are granted. 7. Entitlement to service connection for actinic keratoses with early basal cell changes. The Veteran claims entitlement to service connection for skin cancer, which he asserts is either due to exposure to herbicides or excessive sun during his period of service. See November 2016 notice of disagreement. First, the Veteran has been diagnosed with a skin condition during the appeal period, so there is a current disability. A September 2013 VA record documents the Veteran had a history of lesions on his face since Vietnam and a history of skin cancer removed from his face. December 2013 and January 2017 private medical records report diagnoses of actinic keratoses and pigmented actinic keratosis on the left upper cheek with hyperpigmentation of basal layer keratinocytes. The Veteran was examined by Dr. JE in November 2016, who noted the presence of actinic keratoses on the forehead and evidence of a prior biopsy of the left lateral eye likely related to a basal cell carcinoma. Dr. JE characterized the Veteran’s current skin condition as actinic keratoses with early basal cell changes. At the December 2020 hearing, the Veteran testified that his private physician cut out an area of skin and determined it was an encapsulated malignancy sometime in the 1980s, but those records were not available because the physician was no longer in practice. Overall, the evidence demonstrates actinic keratoses with early basal cell changes/hyperpigmentation of basal layer keratinocytes but not current basal cell carcinoma. Second, there is an in-service event. The Veteran relayed to Dr. JE that when he was in Vietnam, he was often not wearing a helmet due to the heat and was exposed to the sun. At the December 2020 hearing, the Veteran recalled significant sun exposure and getting sunburnt and tan during his tour of duty in Vietnam. The Veteran is competent to report his in-service symptoms, and they are consistent with the nature of his combat service in a tropical environment in August. Thus, the evidence establishes significant sun exposure during the Veteran’s period of active duty. Third, it is at least as likely as not that the diagnosed actinic keratoses with early basal cell changes are etiologically related to the in-service sun exposure. The Veteran’s medical provider, Dr. JD, explained that actinic keratoses were caused by excessive sun exposure. See December 2013 private medical record. Dr. JD further explained that sun damage was permanent, and new keratoses could appear later on even without additional exposure. In November 2016, Dr. JE opined that the diagnosed actinic keratoses and early basal cell changes were etiologically related to the Veteran’s in-service sun exposure. Although Dr. JE did not cite review of the available medical evidence, Dr. JE’s findings and conclusion are consistent with the other evidence of record. There is no medical opinion to the contrary. Overall, it is at least as likely as not that the currently diagnosed actinic keratoses with early basal cell changes are etiologically related to the in-service sun exposure. The criteria for service connection are met and the claim is granted. Effective Dates Generally, the effective date of an award of disability compensation based on an original claim shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110(a) (2012); 38 C.F.R. § 3.400. Unless otherwise provided, the effective date of compensation will be fixed in accordance with the facts found but will not be earlier than the date of receipt of the claimant’s application. 38 U.S.C. § 5110(a). If a claim is filed within one year after separation from service, service connection will be effective as of the day after separation. 38 C.F.R. § 3.400(b)(2). Where a claim is granted after the submission of new and material evidence, the effective date is the later of the date of receipt of the new claim or the date entitlement arose. 38 C.F.R. § 3.400(q)(2). Prior to March 24, 2015, a claim was “a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit.” 38 C.F.R. § 3.1(p). An informal claim is “[a]ny communication or action indicating intent to apply for one or more benefits.” 38 C.F.R. § 3.155(a). VA must look to all communications from a claimant that may be interpreted as applications or claims - formal and informal - for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). The essential elements for any claim, whether formal or informal, are: (1) an intent to apply for benefits; (2) an identification of the benefits sought; and (3) a communication in writing. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009); MacPhee v. Nicholson, 459 F.3d 1323, 1326-27 (Fed. Cir. 2006) (holding that the plain language of the regulations requires a claimant to have intent to file a claim for VA benefits). For claims or appeals filed on or after March 24, 2015, a claim for benefits must be submitted on a standardized form. Standard Claims and Appeals Forms, 79 Fed. Reg. 57,660, 57,686 (Sept. 25, 2014) (eff. Mar. 24, 2015). Claims or appeals pending before VA on that date are to be decided based on the regulations as they existed prior to the amendment. Standard Claims and Appeals Forms, 79 Fed. Reg. 57,660, 57,686. With regard to the date of entitlement, the term “date entitlement arose” is the date when the claimant met the requirements for the benefits sought, on a facts found basis. 38 U.S.C. § 5110(a); McGrath v. Gober, 14 Vet. App. 28, 35 (2000). These facts found include the date the disability first manifested and the date entitlement to benefits was authorized by law and regulation. See generally 38 C.F.R. § 3.400. For instance, if a claimant filed a claim for benefits for a disability before he actually had the disability, the effective date for benefits can be no earlier than the date the disability first manifested. Ellington v. Peake, 541 F.3d 1364, 1369-70 (Fed. Cir. 2008). However, the date entitlement arose is not the date that the RO receives the evidence, but the date to which that evidence refers. McGrath, 14 Vet. App. at 35. 8. Entitlement to an effective date prior to November 9, 2016 for the grant of service-connection for right bicep strain. The Veteran’s attorney asserts that the proper effective date for the grant of service-connection for right bicep strain should be April 22, 2013, the date of the Veteran’s initial claim for benefits. Procedurally, the Veteran filed a claim for service connection for a bilateral shoulder condition that was received by VA on April 22, 2013 and denied in December 2013 rating decision. The Veteran did not appeal the December 2013 decision and no new or material evidence was received within one year of that decision. Thus, the December 2013 rating decision became final. On November 9, 2016 the Veteran filed a claim for service connection for a right bicep tendon condition. That claim was denied in a February 2017 rating decision. Then, a November 2017 rating decision granted entitlement to service connection for right bicep tendon strain and made a finding that the February 2017 rating decision had been clearly and unmistakably erroneous. The November 2017 rating decision did not make any finding regarding the December 2013 rating decision and review of the record shows no prior or pending claim of clear and unmistakable error in the December 2013 rating decision that initially denied the claim of service connection for a right shoulder disorder. Here, the proper date of claim is November 9, 2016. That is the date VA received the Veteran’s claim for service-connection for a right bicep tendon injury. Even if the April 22, 2013 claim encompassed the claim for a right bicep injury, the December 2013 rating decision is final. Thus, the proper date of claim would the date VA received the Veteran’s claim to reopen, which is November 9, 2016. From April 22, 2013 to November 9, 2016 there was no informal or formal claim for benefits for a right bicep or right shoulder condition. Accordingly, November 9, 2016 is the proper date of claim. Even if the Veteran met the requirements for the benefit sought on a facts found basis prior to November 9, 2016; the proper effective date is either the date the entitlement arose or the date of claim, whichever is later in time. For these reasons, November 9, 2016 is the proper effective date for the grant of service connection for right bicep strain and the claim to an earlier effective date is denied. REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea, to include as secondary to PTSD and/or ischemic heart disease is remanded. This issue is remanded for an adequate medical opinion on the etiology the claimed sleep apnea that considers all theories of entitlement. See Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) (holding that a medical opinion should address the appropriate theories of entitlement). The Veteran asserts that sleep apnea is etiologically related to service-connected PTSD. See June 2016 claim. At the December 2020 hearing, the Veteran’s attorney raised the possibility that sleep apnea was due to obesity, and that obesity was due to service-connected ischemic heart disease. VA obtained a medical opinion in July 2016. That examiner opined that diagnosed obstructive sleep apnea was not due to or the result of service-connected PTSD. The examiner explained that PTSD was a separate and distinct condition, and that obstructive sleep apnea was caused by the recurrent collapse of the pharyngeal airway during sleep. PTSD, however, was characterized by different kinds of sleep disturbance, such as nightmares and insomnia. PTSD did not cause the anatomical or physiological changes associated with sleep apnea. Thus, the examiner concluded that the obstructive sleep apnea was not caused by PTSD. In November 2016, Dr. JE opined that sleep apnea was aggravated by service-connected ischemic heart disease and PTSD. In support of that opinion, Dr. JE explained that intrusive thoughts from PTSD interrupted the Veteran’s sleep and that the Veteran had fluid on his lungs due to his weak heart muscle. Dr. JE’s assertion that interrupted sleep due to PTSD aggravated sleep apnea is cursory and the rationale less thorough than that of the July 2016 VA examiner. Regarding the second opinion, Dr. JE cited to no medical evidence of fluid in the lungs and did not record any on examination of the Veteran. A December 2016 VA examination report documents the Veteran did not have congestive heart failure and his chest x-rays were normal. The November 2016 opinions of Dr. JE are insufficient to form the sole basis of a grant of service connection. The July 2016 VA examiner did not provide a distinct opinion on whether PTSD aggravated obstructive sleep apnea. Where a VA examiner did not specifically opine as to whether a disability was aggravated (as distinct from caused) by a service-connected disability, soliciting such an opinion is necessary to adjudicate the appeal. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013); see also Allen v. Brown, 7 Vet. App. 439 (1995). As a result, a remand is required to address the aggravation theory. Also, since the 2016 examination the Veteran’s attorney has reasonably raised the theory of service connection secondary to ischemic heart disease with obesity as an intermediate step. A June 2007 private sleep study report includes a recommendation that the Veteran lose weight. A December 2016 VA examination report documents the Veteran “huffs and puffs” if walking a mile and was functionally limited in some activities due to ischemic heart disease. At the December 2020 hearing, the Veteran reported that his weight was higher around the time first began to experience sleep apnea symptoms, and he attributed his weight gain to not exercising. On remand, VA should obtain addendum opinions that fully address this additional theory of entitlement. 2. Entitlement to service connection for a right elbow disorder, to include as secondary to service-connected right bicep strain. This issue is also remanded for an adequate medical opinion on the etiology of the claimed right elbow disorder that considers all theories of entitlement. The Veteran alleges that a right elbow condition began during service and was caused by overuse from carrying a radio with his right arm during the Vietnam war. See February 2017 notice of disagreement. He has also described chronic right elbow symptoms since the in-service onset. See id. In November 2016 the Veteran submitted a private medical report and opinion completed by Dr. JE. Dr. JE interviewed the Veteran and documented an incident in service where the Veteran fell while on infantry patrol and landed on his outstretched right arm. The Veteran ruptured his right bicep tendon and experienced ongoing symptoms of weakness in service. Dr. JE opined it was more likely than not that the retraction of the tendon due to the rupture caused the tendons of the medial aspect of the right elbow to pull, causing medial epicondylitis. Dr. JE only cited review of the Veteran’s DD 214 and a September 2016 rating decision. A December 2016 VA examiner opined that the diagnosed right medial epicondylitis was not caused by the right bicep injury in service. The examiner explained that epicondylitis was an overuse tendinopathy that affected the muscles of the forearm. Repeated overuse like gripping or swinging could cause small tears in the tendon, typically found in the dominant arm. The examiner went on to explain that because the epicondylitis was bilateral, it was not likely caused by the unilateral right bicep tendonitis/strain. The December 2016 VA examiner cited review of the entire claims file. Neither medical opinion is sufficient to decide the claim. Although Dr. JE opined that the right medical epicondylitis is secondary to the right bicep strain, the December 2016 VA examiner highlighted the fact the Veteran had bilateral medial epicondylitis despite the unilateral bicep tendon strain. Dr. JE did not review any of the Veteran’s medical records and did not discuss the significance of the bilateral medial epicondylitis when providing the opinion, thus the opinion is not fully adequate and cannot form the sole basis of a grant of service connection. The December 2016 VA examiner failed to address the Veteran’s claim that the right elbow disorder is due to overuse during his period of service and independent of the right bicep tendon injury, and did not provide a distinct opinion with rationale as to whether the right medial epicondylitis was aggravated by the right bicep strain. Thus, remand for an addendum is required. The medical evidence in this case is sparse and the record indicates there are outstanding private medical records relevant to the remaining claims on appeal. See December 2020 hearing testimony. On remand, VA should undertake reasonable efforts to identify and obtain the outstanding and relevant private treatment records. The matters are REMANDED for the following action: 1. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant private medical records. Undertake reasonable efforts to obtain all the records from all the sources listed by the Veteran which are not already on file. All attempts to secure this evidence must be documented in the claims file. If the evidence is not secured, provide the required notice and opportunity to respond to the Veteran and his representative. 2. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the sleep apnea from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that sleep apnea is aggravated (worsened beyond its natural progression) by service-connected PTSD. (b.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the sleep apnea is caused or aggravated by service-connected ischemic heart disease. (c.) The examiner must specifically address the theory that the Veteran’s sleep apnea is due to obesity, and that obesity is due to service-connected ischemic heart disease: i. Is it at least as likely as not (at least a 50 percent probability) that the Veteran’s service-connected ischemic heart disease caused the Veteran’s obesity? ii. Is it at least as likely as not (at least a 50 percent probability) that the Veteran’s service-connected ischemic heart disease aggravated (worsened beyond its natural progression) the Veteran’s obesity? iii. If the answer to (i) or (ii) is yes, then is it at least as likely as not that the Veteran’s sleep apnea would not have occurred but for his obesity? In forming these opinions the examiner should consider the June 2007 private sleep study report (recommending that the Veteran lose weight); a December 2016 VA examination report (documenting the functional impairment due to ischemic heart disease); and the December 2020 hearing testimony (the Veteran reported that his weight was higher around the time first began to experience sleep apnea symptoms, and he attributed his weight gain to not exercising). 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the right medial epicondylitis from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. A physical examination is not necessary unless deemed so by the examiner. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that right medial epicondylitis is etiologically related to the Veteran’s period of service, to include as due to overuse from carrying military equipment. (b.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that right medial epicondylitis is aggravated (worsened beyond its natural progression) by the service-connected right bicep strain. In the rationale for these opinions, the examiner should address the following: 1) the Veteran’s testimony that he had chronic elbow pain since his period of service that he attributes to overuse from carrying military equipment with his right arm; and 2) the November 2016 private medical opinion of Dr. JE. LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Smith, 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.