Citation Nr: 21028318 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 09-45 417 DATE: May 11, 2021 ORDER As the claim is withdrawn, the claim of entitlement to an effective date prior to September 24, 2015, for the grant of service connection for tinnitus is dismissed. As the claim is withdrawn, the claim of entitlement to an initial rating in excess of 10 percent for tinnitus is dismissed. As the claim is withdrawn, the claim of entitlement to service connection for hypertension is dismissed. As the claim is withdrawn, the claim of entitlement to service connection for a heart disability, to include murmur, is dismissed. As the claim is withdrawn, the claim of whether new and material evidence has been received to reopen the claim of entitlement to service connection for a left leg disability is dismissed. As the claim is withdrawn, the claim of whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right leg disability is dismissed. An effective date earlier than July 30, 2007, for the grant of service connection for right ankle sprain is denied. REMANDED Entitlement to service connection for diabetes mellitus, type II, is remanded. Entitlement to service connection for a skin disability of the feet, to include rash, is remanded. Entitlement to service connection for skin disability of the ankles, to include rash, is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to a rating in excess of 30 percent for asthma is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability is remanded. FINDINGS OF FACT 1. On March 10, 2021, prior to the promulgation of a decision in the appeal, the Board of Veterans' Appeals (Board) received explicit and unambiguous notification from the Veteran, through his authorized representative, that he sought to withdraw his claim of entitlement to an effective date prior to September 24, 2015, for the grant of service connection for tinnitus. 2. On March 10, 2021, prior to the promulgation of a decision in the appeal, the Board received explicit and unambiguous notification from the Veteran, through his authorized representative, that he sought to withdraw his claim of entitlement to an initial rating in excess of 10 percent for tinnitus. 3. On March 10, 2021, prior to the promulgation of a decision in the appeal, the Board received explicit and unambiguous notification from the Veteran, through his authorized representative, that he sought to withdraw his claim of entitlement to service connection for hypertension. 4. On March 10, 2021, prior to the promulgation of a decision in the appeal, the Board received explicit and unambiguous notification from the Veteran, through his authorized representative, that he sought to withdraw his claim of entitlement to service connection for a heart disability, to include murmur. 5. On March 10, 2021, prior to the promulgation of a decision in the appeal, the Board received explicit and unambiguous notification from the Veteran, through his authorized representative, that he sought to withdraw his claim of whether new and material evidence has been received to reopen the claim of entitlement to service connection for a left leg disability. 6. On March 10, 2021, prior to the promulgation of a decision in the appeal, the Board received explicit and unambiguous notification from the Veteran, through his authorized representative, that he sought to withdraw his claim of whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right leg disability. 7. A June 2006 Board decision denied the claim of entitlement to service connection for right ankle sprain; the Veteran was notified of his rights but did not appeal or request reconsideration and the decision became final. 8. The Department of Veterans Affairs (VA) received the Veteran's petition to reopen the previously denied claim for service connection for right ankle sprain on July 30, 2007; the effective date of the award of compensation cannot be earlier than the date of receipt of the claim to reopen. 9. After the June 2006 prior final disallowance and before the claim received on July 30, 2007, there are no pending unadjudicated claims for service connection for right ankle sprain. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claim of entitlement to an effective date prior to September 24, 2015, for the grant of service connection for tinnitus by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of the claim of entitlement to an initial rating in excess of 10 percent for tinnitus by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for withdrawal of the claim of entitlement to service connection for hypertension by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The criteria for withdrawal of the claim of entitlement to service connection for a heart disability, to include murmur, by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 5. The criteria for withdrawal of the claim of whether new and material evidence has been received to reopen the claim of entitlement to service connection for a left leg disability by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 6. The criteria for withdrawal of the claim of whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right leg disability by the Veteran have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 7. The June 2006 Board decision denying the claim of entitlement to service connection for right ankle sprain is final. 38 U.S.C. § 7104; 38 C.F.R. § 20.1104. 8. The criteria for an effective date earlier than July 30, 2007, for the grant of service connection for right ankle strain have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(q). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1969 to September 1975. This appeal comes before the Board from rating decisions of a VA Regional Office (RO). In April 2016, the Veteran was scheduled for a Board hearing; he, however, withdrew his request for a Board hearing. See VA Form 21-4138 (February 2016). As such, the Veteran's hearing request is withdrawn. 38 C.F.R. § 20.704(e). Dismissal 1. Entitlement to an effective date prior to September 24, 2015, for the grant of service connection for tinnitus is dismissed. 2. Entitlement to an initial rating in excess of 10 percent for tinnitus is dismissed. 3. Entitlement to service connection for hypertension is dismissed. 4. Entitlement to service connection for a heart disability, to include murmur, is dismissed. 5. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a left leg disability is dismissed. 6. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right leg disability is dismissed. Issues 1-6. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his or her authorized representative. Unless an appeal is withdrawn on the record at a hearing, appeal withdrawals must be in writing and must include the name of the veteran, the name of the claimant or appellant if other than the veteran, the applicable VA file number, and a statement that the appeal is withdrawn. If the appeal involves multiple issues, the withdrawal must specify that the appeal is withdrawn in its entirety or list the issue(s) withdrawn from the appeal. 38 C.F.R. § 19.55(b)(1). Until the appeal is transferred to the Board, an appeal withdrawal is effective when received by the agency of original jurisdiction (AOJ). 38 C.F.R. § 19.55(b)(3). In the present case, on March 10, 2021, the Board received notification from the Veteran indicating that he sought to withdraw the above issues. See VA Form 21-4138 (March 2021). The withdrawal is in writing and contains the Veteran's name, VA file number, and a statement indicating that the Veteran wished to withdraw the above claims on appeal. 38 C.F.R. § 19.55(b)(1). Hence, there remains no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal of these matters and they are dismissed. Earlier Effective Date 7. Entitlement to an effective date prior to July 30, 2007, for the grant of service connection for right ankle sprain. A February 2008 rating decision granted the Veteran service connection for right ankle sprain and assigned an effective date of July 30, 2007. The Veteran appealed this decision. The Veteran seeks an earlier effective date than assigned for the grant of service connection for right ankle sprain. In support of this argument, the Veteran argues that his effective date should be when he originally submitted his claim, April 10, 2002, because "of the slowness of the system and the miss diagnoses of the 2005 VA examination." See NOD (May 2008). The Board concludes that the preponderance of the evidence is against an effective date earlier than July 30, 2007, for the grant of service connection for right ankle sprain because the award is based on a reopened claim after a final disallowance. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(q). VA regulations state that, except as otherwise provided, the effective date of an award of compensation based on a claim to reopen after final disallowance will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400; see also 38 C.F.R. § 3.400(q)(2) (providing the same for awards of compensation based on new and material evidence received after final disallowance); 38 C.F.R. § 3.400(r) (providing the same for awards of compensation based on reopened claims). Prior to March 24, 2015, VA defined a "claim" as "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) (2014); 79 Fed. Reg. 57,696 (Sept. 25, 2014) (effective March 24, 2015) (eliminating the informal claims). An informal claim was defined as "[a]ny communication or action indicating an intent to apply for one or more benefits." 38 C.F.R. § 3.155(a) (2014). Thus, the essential elements for a claim, whether formal or informal, were "(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing" for the relevant time period for this appeal. Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). By way of history, the record reflects that the Veteran first filed a claim of entitlement to service connection for right ankle sprain in April 2002. The AOJ denied the Veteran's claim in an April 2003 rating decision. The Veteran filed an informal notice of disagreement (NOD) in February 2004, and the AOJ issued a statement of the case in April 2004, and the Veteran filed a substantive appeal (VA Form 9) in June 2004. Following additional development, the Board, in a June 2006 decision, denied service connection for residuals of a right ankle strain. The Veteran was notified of his rights but did not appeal or request reconsideration. 38 U.S.C. §§ 7103, 7266; 38 C.F.R. § 20.1000. As such, the Board decision is final. 38 C.F.R. § 20.1100. On July 30, 2007, VA received an informal claim requesting reopening and service connection for right ankle condition. A February 2008 rating decision, subsequently, granted service connection for right ankle sprain and assigned an effective date of July 30, 2007. Then, in May 2008, the Veteran submitted an informal NOD requesting an earlier effective date for the grant of service connection for right ankle strain. Based on the above facts, the AOJ correctly found that the effective date for the award of service connection is July 30, 2007, as the effective date for a reopened claim after a final disallowance shall be the date of receipt of the new claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(q)(1)(ii). The Veteran has not identified nor has the Board's review of the record disclosed a claim, formal or informal, prior to July 30, 2007, and after the June 2006 Board decision. 38 C.F.R. §§ 3.1(p), 3.155(a). Brokowski, 23 Vet. App. at 84; 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). The Board further notes that a Board decision is final unless the Chairman of the Board orders reconsideration. See 38 U.S.C. §§ 7103(a), 7104; 38 C.F.R. § 20.1100(a). In this regard, the record reveals that after the Board denial, in June 2006, the Veteran did not appeal that decision to the United States Court of Appeals for Veterans Claims within 120 days of the issuance of the Board decision, nor did he request reconsideration of that decision. Thus, the June 2006 Board decision became final. As such, the Board finds that the evidence of record provides no basis for an award of service connection for right ankle strain prior to July 30, 2007. Accordingly, the claim is denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). REASONS FOR REMAND In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. 1. Entitlement to service connection for diabetes mellitus, type II, is remanded. 2. Entitlement to service connection for a skin disability of the feet, to include rash, is remanded. 3. Entitlement to service connection for a skin disability of the ankles, to include rash, is remanded. Issues 1-3. The Veteran, and his representative, contends that his disabilities stem from in-service herbicide agent exposure. In this regard, the Veteran maintains that he was exposed to herbicide agents in the contiguous waters of the Republic of Vietnam, or, in the alternative, while stationed in Okinawa, Japan. See VA Form 21-4138 (July 2009), Form 9 (March 2010) & From 9 (June 2010). For reasons explained below, the Board finds that remand is necessary. Recently, in Procopio v. Wilkie, 913 F.3d 1371, 1379 (Fed Cir. 2019), the United States Court of Appeals for the Federal Circuit clarified that the term "Republic of Vietnam" refers to both the Republic of Vietnam's "landmass and its 12 nautical mile territorial sea." More recently, Congress enacted new statutory requirements for the adjudications of certain claims based on herbicide agent exposure in the offshore waters of the Republic of Vietnam. The Blue Water Act defines service "offshore of the Republic of Vietnam" as encompassing service in the territorial sea extending 12 nautical miles from the shores both the Republic of Vietnam and Cambodia. See 38 U.S.C. § 1116A(d). The Act provides that the 12 miles are measured seaward of a line commencing on the southwestern demarcation line of the waters of Vietnam and Cambodia an intersecting at certain points (latitude North, longitude East); these are set out in a Points Geographic table included there. See 38 U.S.C. § 1116A(d). Under the Act, a veteran's service must take place between January 9, 1962, and May 7, 1975. 38 U.S.C. § 1116A(a). Service personnel record, dated in February 1971, shows that the Veteran served in the contiguous waters of the Republic of Vietnam. See Military Personnel Record (February 1971), A November 2015 Formal Finding reveals that it was determined that the information required to verify herbicide agent exposure was insufficient to send to the Joint Services Records Research Center. However, that determination was made prior to the enactment of the Blue Water Act. Accordingly, the Board finds that a remand is necessary to determine whether the Veteran served in Vietnam, to include its 12 nautical mile territorial sea. See 38 U.S.C. § 1116A; 38 C.F.R. § 20.904(a). 4. Entitlement to service connection for OSA is remanded. The Veteran, and his representative, contends that his OSA is secondary to his service-connected asthma and right ankle disability. With regard to the right ankle disability, the Veteran's representative maintains that the OSA stems from the prescribed opioid pain medication. The Board finds that remand is necessary. Private medical opinion, dated in April 2018, reflects the conclusion that "it is as likely as not the Veteran's service-connected asthma and his prescribed opioid pain for his service-connected ankle condition aided in the development of and permanently aggravate his OSA." In support of the conclusion, the opinion notes that, "It is well known within the medical community that any condition which adversely affects a patient's breathing both contributes to and aggravates sleep apnea." The opinion, additionally, notes that "medical research has shown long term narcotic use for pain cause, precipitates or exacerbates sleep disordered breathing." The Board finds the private medical opinion inadequate to support the claim. Hayes v. Brown, 5 Vet. App. 60, 69 (1993). Here, the opinion notes that "any condition which adversely affects a patient's breathing both contributes to and aggravates sleep apnea," however, it does not seem to acknowledge that aside from his service-connected asthma, the Veteran additionally has been diagnosed with restrictive lung disease, which has been found that it could "be related to idiopathic causes, intrinsic causes of the lung parenchyma, and extrinsic causes such as obesity." See C&P Exam (December 2015). The opinion, however, does not reveal a discussion or rationale on this significant finding in the Veteran's treatment records. Indeed, the opinion is absent of any relevant discussion or analysis that the Board can weigh against the evidence. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("a medical opinion . . . must support its conclusion with analysis that the Board can consider and weigh against contrary opinions"). Next, although the opinion notes that the Veteran has a history for hydrocodone, it does not provide the Board with a discussion on whether such prescription was for his nonservice-connected bilateral knee condition, service-connected right ankle disability, or both. In this regard, the Board observes that there are multiple entries in the Veteran's treatment records, in which, he has been prescribed hydrocodone for his chronic bilateral knee pain, left foot pain, and for a left fifth toe partial amputation. The opinion, nevertheless, does not reveal consideration of this fact and, thus, is not shown to be based on an accurate factual premise with consideration of the Veteran's prior medical history. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). Lastly, the opinion references medical literature that support the conclusion, however, the opinion does not provide or reflect consideration of facts specific to the Veteran vis-à-vis the medical literature that was reviewed. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (stating that a medical rationale based solely on general medical literature without discussing the specific facts pertaining to a veteran's condition or individual circumstances is inadequate). Indeed, the medical literature referenced in the opinion reveals findings, however, the opinion is absent of a rationale that connects the findings to the conclusion. Nevertheless, given the above, there is sufficient competent evidence to warrant remand for a VA examination and medical opinion. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). VA has not yet obtained a medical opinion or examination in this matter. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran, and his representative, contends that his acquired psychiatric disorder is secondary to his service-connected asthma, right ankle disability, and tinnitus. He further maintains that it is secondary to his nonservice-connected OSA. See Third Party Correspondence (May 2018). The Board finds that remand is necessary. Private medical opinion, dated in April 2018, reflects the conclusion that the Veteran's "asthma, right ankle sprain, tinnitus and OSA are more likely than not causing his depressive disorder . . . ." The Board finds the private medical opinion inadequate to support the claim. Hayes, 5 Vet. App. at 69. In this instance, the opinion's conclusion, first, is based on several medical conditions, to include nonservice-connected OSA, and is not limited to the Veteran's service-connected disabilities. Additionally, it is noted that the Veteran has multiple nonservice-connected disabilities, to include OSA, hypertension, hyperlipidemia, bilateral knee conditions, and chronic renal insufficiency. See VAMC (September 2017). The opinion, however, does not differentiate or distinguish between the conditions and, in this case, seems to disregard all of the Veteran's nonservice-connected health conditions. Second, the opinion is inadequate because, as support for its conclusion, it relied on an association between his acquired psychiatric disorder and the service-connected disabilities. For example, the opinion states that medical literature "detail[s] the association between tinnitus and comorbid psychological disorders including a high prevalence of anxiety and depression in tinnitus sufferers." (Emphasis added). For the Veteran's service-connected asthma, the opinion notes that, "Researchers indicate that chronic physical problems are reported to be associated with increased rates of depression along with the link between increased mortality rate in depressed patients with asthma." (Emphasis added). Thus, the opinion reflects an analysis based on association rather than causation. See Atencio v. O'Rourke, 30 Vet. App. 74, 90-91 (2018) (holding that a medical opinion was inadequate when it was unclear whether the examiner had clearly provided a rationale that dealt with causation and aggravation as independent concepts). In other words, secondary service connection requires a causal relationship (not an association) between the current disability and service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Lastly, the Board finds the private medical opinion inadequate because it is not shown to be based on an accurate factual premise with consideration of the Veteran's prior medical history. Ardison, 6 Vet. App. at 407. Here, the record reveals that the Veteran has attributed his depressive disorder to his health, but also financial concerns. See, e.g., VAMC (October 2008) (revealing that the Veteran reported "feeling depressed and stressed over finances and health issues"); see also VAMC (July 2014) (showing that the Veteran attributed his depression to "external issues"). The opinion, however, does not show a discussion or clarification on the contrary findings in the Veteran's treatment records. Further, as discussed above, the opinion also does not reveal a discussion or reasoned medical rationale differentiating between the service-connected and nonservice-connected disabilities. Consequently, for the above reasons, the Board finds the private medical opinion inadequate to support the claim. Nevertheless, given the above, there is sufficient competent evidence to warrant remand for a VA examination and medical opinion. See Colvin, 1 Vet. App. 171. VA has not yet obtained a medical opinion or examination in this matter. McLendon, 20 Vet. App. 79. 6. Entitlement to a rating in excess of 30 percent for asthma is remanded. The Veteran, and his representative, contends that a higher evaluation for his service-connected asthma is warranted. In March 2021, the Veteran reported increased symptomology as related to his asthma. In this regard, he reported difficulty breathing, easily fatiguing, limited movement, and difficulty doing daily task. See VA Form 21-4138 (March 2021). He additionally reported not being able to work due to his condition. Id. While the mere passage of time is not grounds for a new examination, a new examination is appropriate when there is an assertion (and indication) of an increase in severity since the last examination. See 38 C.F.R. § 3.159; see also Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Here, the record reflects that the Veteran was last examined for his condition in December 2015, in which, he reported being limited from heavy physical work but not from sedentary work or light physical work based on his disability. Nonetheless, lay reports, as evidenced in March 2021, indicate that the Veteran's asthma disability now limits his ability to do light physical work. Given the competent evidence of worsened symptoms since his last VA examination, a remand is necessary to adequately evaluate the current severity of the Veteran's service-connected asthma. Caffrey v. Brown, 6 Vet. App. 377, 381 (1995) (VA must provide a new examination where a veteran claims the disability is worse than when originally rated and the available evidence is too old to adequately evaluate the current severity). Therefore, a new VA examination is needed to assist in determining the current severity of the Veteran's service-connected disability. Snuffer, 10 Vet. App. at 400. 7. Entitlement to a TDIU due to service-connected disability is remanded. In conjunction with the claim for increase for his service-connected asthma, the Veteran submitted lay reports indicating that he could not work as due to his disability. See VA Form 21-4138 (March 2021). Although this matter is part-and-parcel of the claim for increase, it has not been developed or adjudicated by the originating agency in the first instance. 38 C.F.R. § 3.155(d)(2) (as part of a claim, VA must adjudicate entitlement to any ancillary benefits for complications of the claimed condition). See also Rice v. Shinseki, 22 Vet. App. 447 (2009). The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a TDIU claim form (VA Form 21-8940) and ensure that he receives appropriate notice of how to substantiate a claim of entitlement to a TDIU. 2. Attempt to verify the Veteran's asserted in-service exposure to herbicide agents for while (1) on the contiguous waters of the Republic of Vietnam, and (2) stationed in Okinawa, Japan. If more details are needed, contact the Veteran to request the information. If there is still insufficient information to verify exposure to herbicide agents, issue a Formal Finding outlining the steps taken to assist the Veteran and notify the Veteran of VA's inability to verify the in-service herbicide agent exposure. 3. Obtain all VA treatment records dated from November 2017 to the Present. 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected asthma. (a) The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (b) For TDIU purposes: (i) Elicit from the Veteran his complete educational, vocational, and employment history. (ii) Ask the Veteran to describe in his own words the functional impact of his asthma on his ability to perform the physical and mental acts required for substantially gainful work. The Veteran's response should be recorded in the examination report. (iii) Indicate the objective functional effects of the Veteran's asthma on his ability to perform the physical acts (e.g., walking, sitting, standing, bending) and mental acts (e.g., concentration, focus, attention, and memory) required for employment. 5. Schedule the Veteran for an examination(s) by an appropriate clinician(s) to determine the nature and etiology of any (1) OSA, and (2) acquired psychiatric disorder. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician(s). Based on examination and review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with any of the above disabilities. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician must opine on: OSA (a) Whether the Veteran's OSA is at least as likely as not (1) proximately due to service-connected asthma or (2) aggravated beyond its natural progression by service-connected asthma. Provide a rationale that deals with causation and aggravation as independent concepts. Consider and expressly address (1) the relevant medical literature of record, and (2) the April 2018 private medical opinion. Explain. (b) Whether the Veteran's OSA is at least as likely as not (1) proximately due to service-connected right ankle disability or (2) aggravated beyond its natural progression by service-connected right ankle disability. Provide a rationale that deals with causation and aggravation as independent concepts. Consider and expressly address (1) the relevant medical literature of record, and (2) the April 2018 private medical opinion. Explain. Acquired Psychiatric Disorder (c) Whether the Veteran's acquired psychiatric disorder is at least as likely as not (1) proximately due to service-connected asthma or (2) aggravated beyond its natural progression by service-connected asthma. Provide a rationale that deals with causation and aggravation as independent concepts. Consider and expressly address (1) the relevant medical literature of record, and (2) the April 2018 private medical opinion. Explain. (d) Whether the Veteran's acquired psychiatric disorder is at least as likely as not (1) proximately due to service-connected right ankle disability or (2) aggravated beyond its natural progression by service-connected right ankle disability. Provide a rationale that deals with causation and aggravation as independent concepts. Consider and expressly address (1) the relevant medical literature of record, and (2) the April 2018 private medical opinion. Explain. (e) Whether the Veteran's acquired psychiatric disorder is at least as likely as not (1) proximately due to service-connected tinnitus or (2) aggravated beyond its natural progression by service-connected tinnitus. Provide a rationale that deals with causation and aggravation as independent concepts. Consider and expressly address (1) the relevant medical literature of record, and (2) the April 2018 private medical opinion. Explain. (f) If the Veteran is found to have OSA service-connected, then opine on whether his acquired psychiatric disorder is at least as likely as not (1) proximately due to service-connected OSA, or (2) aggravated beyond its natural progression by service-connected OSA. Consider and expressly address (1) the relevant medical literature of record, and (2) the April 2018 private medical opinion. Explain. 6. If the Veteran is found to have been exposed to herbicide agents while in service, then schedule the Veteran for an examination(s) by an appropriate clinician(s) to determine the nature and etiology of any (1) diabetes mellitus, type II, (2) bilateral foot skin disability, and (3) bilateral ankle skin disability. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician(s). Based on examination and review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with any of the above disabilities. The opinion must identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. Further, the rationale must reflect an analysis based on causation rather than association. It is noted that direct service connection requires a causal relationship (not an association) between the current disability and the in-service disease or injury. The clinician must opine on: (a) Whether the Veteran's diabetes mellitus, type II, at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease. Consider and expressly address the Veteran's theory that his disability stems from in-service exposure to herbicide agents. Explain. (b) Whether the Veteran's bilateral foot skin disability at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease. Consider and expressly address the Veteran's theory that his disability stems from in-service exposure to herbicide agents. Explain. (c) Whether the Veteran's bilateral ankle skin disability at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease. Consider and expressly address the Veteran's theory that his disability stems from in-service exposure to herbicide agents. Explain. 7. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 8. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Griffey, Associate 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.