Citation Nr: 21028763 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 14-20 416A DATE: May 12, 2021 ORDER Entitlement to a disability rating of 20 percent, but not higher, for keloid scars at anterior chest is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for chronic obstructive pulmonary disease (COPD), to include as secondary to exposure ot herbicide agents and/or service-connected disability, is remanded. Entitlement to service connection for right upper extremity peripheral neuropathy, to include as secondary to service-connected Type II diabetes mellitus, is remanded. Entitlement to service connection for left upper extremity peripheral neuropathy, to include as secondary to service-connected Type II diabetes mellitus, is remanded. Entitlement to service connection for erectile dysfunction as secondary to service-connected Type II diabetes mellitus and hypertension is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDING OF FACT Resolving any reasonable doubt in the Veteran's favor, the Veteran has four residual keloid scars at mid-sternum that have been painful, but not unstable, throughout the appeal period. CONCLUSION OF LAW The criteria for a disability rating of 20 percent, but not higher, for keloid scars at anterior chest are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.118, Diagnostic Code 7804 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the appellant in this case, served on active duty from September 1969 to September 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated May 2011, May 2013, and May 2014 of a Department of Veterans' Affairs (VA) Regional Office. In April 2018, the Veteran and his spouse testified during a video-conference hearing before the undersigned Veterans Law Judge (VLJ). During the Board hearing, the Veteran requested to withdraw his appeal seeking entitlement to service connection for cataracts. A copy of the hearing transcript is of record and has been reviewed. Thereafter, the Veteran was afforded a Board hearing in May 2018; however, due to technical difficulties, the Board was unable to obtain a transcript of the hearing, and in December 2018 the Board notified the Veteran that he could attend an additional hearing. However, the Veteran responded that he did not wish to appear at another hearing, and as such, the Board considered the appeal on the evidence of record. In January 2019, the Board dismissed the cataracts claim, granted service connection for hypertension and sleep apnea, and remanded service connection claims for glaucoma, COPD, erectile dysfunction, right and left upper extremity peripheral neuropathy, an acquired psychiatric disorder, and the claim for an increased rating for keloids at the anterior chest for additional development. Thereafter, the Veteran requested a Board hearing, and in January 2021, he testified at a virtual hearing before the undersigned VLJ. A copy of the hearing transcript is of record and has been reviewed. During the January 2021 hearing, the undersigned VLJ recognized an inferred claim for entitlement to a TDIU. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a request for a TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation). The Board finds that there has been substantial compliance with its January 2019 remand directives regarding the Veteran's claim for an increased rating for keloid scars. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). However, there has not been substantial compliance regarding the Veteran's service connection claims for COPD, erectile dysfunction, right and left upper extremity peripheral neuropathy, an acquired psychiatric disorder, and the claim for entitlement to a TDIU, necessitating remand of those claims. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). Entitlement to Compensable Rating for Keloid Scars Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis, and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to her through her senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 137. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Analysis The RO assigned an initial noncompensable disability rating for the Veteran's keloid surgical scar under Diagnostic Code (DC) 7899-7819 based on a single keloid scar at the anterior chest that caused no functional impairment. 38 C.F.R. § 4.118, DC 7899-7819. See Rating Decision dated December 4, 1991 at pgs. 3-4. The Veteran generally claims that a compensable rating is warranted. There are several diagnostic codes that pertain to scars. The Board notes that revised provisions for evaluating scars were enacted effective August 13, 2018. 83 Fed. Reg. 32,592 (July 13, 2018). The amendments apply to claims that were pending on August 13, 2018 (such as here), if the new regulations are more favorable to the Veteran's claim. A review of the amendments shows that only DCs 7801 and 7802 were revised. Pre-August 13, 2018, DC 7801 provides that scars of other than the head, face or neck that are deep and nonlinear are assigned ratings based on the area or areas of the scar(s). DC 7801 provides a 10 percent rating for scars at least 39 square centimeters but less than 77 square centimeters, a 20 percent rating for scars at least 77 square centimeters but less than 465 square centimeters, a 30 percent rating for scars at least 465 square centimeters but less than 929 square centimeters, and a 40 percent rating for scars 929 square centimeters or greater. Effective August 13, 2018, DC 7801 was amended to remove characterization as "deep and nonlinear scars" which was replaced with characterization of scars with "underlying soft tissue damage." 38 C.F.R. § 4.118, DC 7801. Pre-August 13, 2018, DC 7802 provides a 10 percent rating for scars of other than the head, face or neck that are superficial and nonlinear if the area or areas of the scars is 144 sq. in. (929 sq. cm.) or greater. Id. DC 7802 was amended to remove "superficial and nonlinear" and was replaced with "not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DC 7802. DC 7804 was unaffected by the revision of the rating criteria effective August 13, 2018. Based on either the pre-August 13, 2018 or the new rating criteria, DC 7804 allows for compensable ratings for unstable or painful scars. 38 C.F.R. § 4.118, DC 7804. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. at Note 1. Under DC 7804, a 10 percent rating is warranted for one or two scars that are unstable (frequent loss of covering of the skin over the scar) or painful. A 20 percent rating is warranted for three or four scars that are unstable or painful, with a maximum 30 percent rating warranted for five or more scars that are unstable or painful. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, DC 7804, Note (1). If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. See 38 C.F.R. § 4.118, DC 7804, Note (2). DC 7805 also was unaffected by the revision of the rating criteria effective August 13, 2018. Based on either the pre-August 13, 2018 or the new rating criteria, DC 7805 applies to other scars (including linear scars) and other effects of scars evaluated under DCs 7800, 7801, 7802, and 7804, and VA is to evaluate any disabling effect(s) not considered in a rating provided under such DCs under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805. The Board finds that the Veteran's keloid scars are appropriately evaluated under DC 7804 for unstable or painful scars. Turning to the relevant evidence, an August 2010 outpatient record from Eglin Air Force Base medical center reflects that the physician noted observing three keloids at the right anterior chest, with no signs of infection. In a September 2010 statement, the Veteran asserted that he had four keloids on his chest, and in his March 2012 Notice of Disagreement, the Veteran noted that the number of keloids on his anterior chest had increased by three. An April 2016 VA skin diseases examination report reflects a diagnosis of bilateral tinea pedis. Although the Veteran's keloids are not mentioned the examiner noted that the Veteran's skin conditions do not cause scarring or disfigurement of his head, face, or neck. During the April 2018 Board hearing, the Veteran stated that his keloids are tender to the touch but denied that the scar covering would fall off. During the Veteran's Board hearing in January 2021, he stated that his keloids are tender to the touch and had grown larger. The Veteran was afforded a VA skin diseases examination in January 2020. The examiner noted one keloid scar on the Veteran's chest at mid sternum measuring 2 cm x 0.5 cm. The examiner noted that the Veteran's scar does not cause scarring or disfigurement of his head, face, or neck. The Veteran reported itching and discomfort associated with the scar as well as past steroid injections to ameliorate symptoms. The examiner concluded that the Veteran's scar caused no functional limitations. See VA skin diseases examination report dated January 29, 2020. Although the January 2020 VA examination report reflects that the Veteran has only one keloid scar, the Veteran has competently and credibly testified that he has four keloid scars on his anterior chest, all of which are painful during the entire rating period. See Board hearing transcript dated January 4, 2021 at pg. 22. The Veteran is competent to report the number of scars as well as pain and tenderness of the scars as they constitute observable conditions. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board notes that the December 1991 rating decision and the rating code sheets show that the Veteran was service-connected and rated for multiple keloids. The Board cannot conclude that the evidence fails to show that the Veteran has four tender and painful scars under the provisions of 38 C.F.R. § 4.118, DC 7804. Therefore, resolving any reasonable doubt in the Veteran's favor, the Board finds that a 20 percent rating, but not higher, for keloid scars is warranted for the entire period on appeal. 38 C.F.R. § 4.118, DC 7804. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is again necessary to ensure that due process is followed and there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38C.F.R. § 3.159(c) (2020). Once VA undertakes the effort to provide an examination or medical opinion when developing a service-connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As outlined below, VA examinations and opinions obtained in the development of the Veteran's claims are inadequate for adjudication purposes. Id. Acquired Psychiatric Disorder The Veteran was afforded a VA mental disorders examination in February 2020, during which the examiner's diagnoses included adjustment disorder with mixed anxiety and depressed mood, and unspecified personality disorder. The examiner opined that the Veteran's currently diagnosed adjustment disorder with mixed anxiety and depressed mood is due to his current psychosocial stressors rather than service, exacerbated, in part, by his pre-existing personality disorder. Indeed, the examiner opined that the Veteran's "personality disorder by definition pre-existed service." Service connection cannot be granted for a personality disorder. 38 C.F.R. §§ 3.303(c), 4.9. 4.127; see also Winn v. Brown, 8 Vet. App. 510, 516 (1996), appeal dismissed, 110 F.3d 56 (Fed. Cir. 1997). However, service connection may be granted, in limited circumstances, for a personality disorder where there is a superimposed disease or injury. See VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (1990); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995). As the February 2020 examiner did not opine as to whether the Veteran's personality disorder was subjected to a superimposed disease or injury in service that resulted in a currently diagnosed psychiatric disorder, the January 2020 VA opinion is inadequate. See Barr, supra. The Board acknowledges that the Veteran has emphatically denied having any psychiatric problems prior to service. See Board hearing transcript dated January 4, 2021 at pg. 12. However, a private psychological evaluation submitted by the Veteran in January 2011 suggests that the Veteran had a psychiatric disorder that preexisted his enlistment in the Air Force. Accordingly, the Veteran's claim for service connection for an acquired psychiatric disorder must be remanded to obtain an addendum medical opinion as to the nature and etiology of his current psychiatric disorder(s). See Stegall, supra. COPD The Veteran was afforded a VA respiratory conditions examination in January 2020. The examiner concluded that a nexus between herbicide agent exposure and the Veteran's COPD "cannot be supported by current peer review medical literature." However, the examiner emphasized that "As per medical literature: The most important risk factor for [COPD] is cigarette smoking," citing an article found at uptodate.com. It is not altogether clear that the article cited by the examiner is peer reviewed medical literature, as the web site appears, at least in some respects, to serve as a repository for collaborative efforts by clinicians to aid in the diagnosis and treatment of illnesses. An uptodate.com Internet link provided by the examiner leads to an article entitled Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging, which states, in part: "The most important risk factor for chronic obstructive pulmonary disease (COPD) is cigarette smoking. Other exposures including passive smoke and biomass fuel use also play roles." While the article indicates that smoking is the most significant risk factor for COPD, it clearly reflects that smoking is not the only risk factor. Notably, the article identifies exposure to biomass fuel as a risk factor for COPD, which is potentially relevant to the Veteran's claim since he asserts that his exposure to Agent Orange while serving on active duty in Thailand caused his COPD. Therefore, the Board anticipated that, in relying on the article, the VA examiner would have considered similarities, if any, between exposure to biomass fuels and the Veteran's conceded exposure to tactical herbicide agents such as Agent Orange. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes from its being factually accurate, fully articulated, and having a sound reasoning for the conclusion). Additionally, the VA examiner did not explain why greater weight was accorded the Veteran's history of smoking over his exposure to herbicide agents. Id. Regarding secondary service connection, the examiner opined that the Veteran's COPD was not caused by his service-connected disorders but did not indicate whether it was aggravated by a service-connected disorder. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding that an opinion will be considered inadequate unless it addresses both the caused by and aggravation avenues for secondary service-connection under 38 C.F.R. § 3.310(b)). Therefore, the January 2020 VA medical opinion regarding the etiology of the Veteran's COPD is inadequate. See Barr, supra. Accordingly, remand is necessary to obtain an adequate opinion addressing the etiology of the Veteran's COPD, to include as secondary to exposure ot herbicide agents during service and/or a service-connected disability. See Stegall, supra. Right and Left Upper Extremity Peripheral Neuropathy In January 2020, the Veteran was afforded a VA diabetic sensory-motor peripheral neuropathy examination. The examiner noted that the Veteran does not have, and has never had, a diagnosis of peripheral neuropathy, and that there is insufficient evidence to warrant or confirm a diagnosis of diabetic neuropathy of the upper extremities. Additionally, the examiner relied on 2015 EMG studies rather than having the Veteran undergo new EMG studies for purposes of the 2020 examination, and while the examiner referenced September 2014 treatment notes from Fort Walton Beach Medical Center (received VBMS July 2018) referencing peripheral neuropathy secondary to diabetes mellitus, he did not, as requested by the Board, reconcile this evidence noting diabetic neuropathy with his finding that the Veteran does not have, and has never had, such diagnosis. Moreover, the examiner failed to discuss prior medial findings of idiopathic upper extremity neuropathy reflected in the treatment records, see Nieves-Rodriguez, supra, and the Veteran's lay statements of record complaining of burning, tingling, and numbness in his upper extremities. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (examiner failed to adequately consider the lay statements of record regarding the onset and continuity of the Veteran's symptoms). Therefore, the Board finds the January 2020 VA diabetic sensory-motor peripheral neuropathy examination inadequate. See Barr, supra. Accordingly, remand is necessary to obtain an adequate opinion addressing the etiology of the Veteran's right and left upper extremity peripheral neuropathy. See Stegall, supra. Erectile Dysfunction The VA examiner noted in the January 2020 VA male reproductive system conditions examination report that there is insufficient evidence to warrant or confirm a diagnosis of acute or chronic erectile dysfunction. However, Tricare outpatient treatment records from the Eglin AFB medical center dated March 2018 reflect a diagnosis of erectile disorder. Additionally, the Veteran has asserted erectile dysfunction and he is competent to report such impairment. See Layno, supra. The examiner's failure to recognize this evidence is suggestive that his review of the claims file was cursory at best, which renders the examination report and the associated negative opinion of little or no probative value. See Nieves-Rodriguez, supra. Furthermore, the VA examiner concluded that the Veteran's symptoms are more appropriately diagnosed as "anejaculation," opining, in part, that the disorder is not related to service or the Veteran's service-connected diabetes since the Veteran's reports of symptoms predated his diagnosis of diabetes mellitus. However, the examiner provided no supporting rationale for his negative opinions regarding a nexus with service or for his opinions that the Veteran's erectile dysfunction was not caused by any service-connected conditions. Moreover, the examiner did not indicate whether the Veteran's erectile dysfunction was aggravated by his service-connected diabetes or hypertension. See El Amin, supra. For these reasons the opinion is inadequate. See Barr, supra. Accordingly, remand is necessary to obtain an adequate opinion addressing the nature and etiology of the Veteran's erectile dysfunction. See Stegall, supra. TDIU Entitlement The record as presently developed does not include sufficient evidence upon which to adjudicate the Veteran's TDIU claim. Namely, service connection claims, including COPD, upper extremities peripheral neuropathies, and acquired psychiatric disorder have yet to be fully adjudicated. Therefore, the issue of entitlement to a TDIU is remanded as intertwined with the pending service connection claims. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). The matters are REMANDED for the following action: 1. Implement the Board's decision herein granting an increased rating of 20 percent, but not higher, for the service-connected keloids at anterior chest. 2. Ensure that all outstanding VA treatment records are associated with the claims file. 3. Then, obtain an addendum opinion from a VA examiner who is a board-certified psychiatrist or psychologist (other than the examiner who conducted the January 29, 2020 VA mental disorders examination) regarding the nature and etiology of the Veteran's psychiatric disorder(s). All clinical findings should be reported in detail and correlated to a specific diagnosis(es). The claims file, and a copy of this Remand, must be made available to, and be reviewed by, the examiner. The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have rendered previous VA opinions inadequate. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Identify all currently diagnosed psychiatric disorders since the date of the claim in August 2010, to include depression, anxiety, and personality disorders if indicated. If any previously diagnosed psychiatric disorders are no longer shown, please explain how they have resolved or otherwise no longer result in any pathology. (b) For each currently diagnosed psychiatric disorder, provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) (1) clearly and unmistakably preexisted service, and, if so; (2) clearly and unmistakably was NOT aggravated by service. *To ensure that the correct legal standard is applied, the examiner's opinion MUST BE STATED IN TERMS OF whether the disorder "clearly and unmistakably preexisted service" AND whether the disorder "clearly and unmistakably was NOT aggravated by service." (c) If the Veteran has a personality disorder, provide an opinion as to whether it was subjected to a superimposed disease or injury in service that resulting in a current acquired psychiatric disorder. In other words, does the Veteran have a current psychiatric problem that amounts to a superimposed disability which, at least as likely as not, resulted from, and in addition to, the personality disorder that preexisted active duty? (d) For any psychiatric disorder found not to have clearly and unmistakably preexisted service, is it at least as likely as not (50 percent or greater probability) that such disability onset during service, manifested within one year after service separation, or is otherwise related to the Veteran's service. Specifically address the Veteran's testimony of an incident in service regarding a dog carrying a human limb in its mouth and his reported nightmares related to that incident. See, e.g., Board hearing transcript dated January 4, 2021 at pg. 12 (VBMS entry titled "Hearing Transcript" on 01/04/2021). In answering these questions, the VA examiner should consider the Veteran's lay statements. The examiner should provide a complete rationale for each opinion. Medical and/or scientific literature cited by the examiner should be adequately discussed and correlated to the Veteran's diagnoses and symptomatology. 4. Obtain an addendum opinion from an appropriately qualified VA examiner (other than the examiner who conducted the January 29, 2020 VA respiratory conditions examination) regarding the nature and etiology of the Veteran's respiratory disorder(s), to include COPD. All clinical findings should be reported in detail and correlated to a specific diagnosis(es). The claims file, and a copy of this Remand, must be made available to, and be reviewed by, the examiner. The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have rendered previous VA opinions inadequate. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Identify all currently diagnosed respiratory disorders since the date of the claim in August 2010, to include COPD. (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the respiratory disorder(s) was CAUSED or AGGRAVATED by any service-connected disability, to include Type II diabetes mellitus, hypertension, and sleep apnea. *Any increase/aggravation is sufficient, permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). *Note to examiner: To ensure that the correct legal standard is applied, which is essential for adjudication of this claim, the opinion MUST BE STATED IN TERMS OF whether the disorder was CAUSED or AGGRAVATED by the service-connected disorder. *See the most recent list of the Veteran's service-connected disabilities (see VBMS entry with document type "Rating Decision Codesheet," disabilities are listed under the caption Subject to Compensation). (c) If the answer to (b) is negative, provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed respiratory disorder(s) onset during service or is otherwise etiologically related to service, to include exposure to herbicide agents during service. Note: VA has conceded the Veteran's in-service exposure to herbicide agents. In answering these questions, the VA examiner should consider the Veteran's lay statements. The examiner should provide a complete rationale for each opinion. Medical and/or scientific literature cited by the examiner should be adequately discussed and correlated to the Veteran's diagnoses and symptomatology. 5. Obtain an addendum opinion from an appropriately qualified VA examiner (other than the examiner who conducted the January 29, 2020 VA Diabetic Sensory-Motor Peripheral Neuropathy examination) regarding the nature and etiology of the Veteran's claimed right and left upper extremity peripheral neuropathy(ies). All clinical findings should be reported in detail and correlated to a specific diagnosis(es). The claims file, and a copy of this Remand, must be made available to, and be reviewed by, the examiner. The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have rendered previous VA opinions inadequate. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Identify all currently diagnosed right and left upper extremity peripheral neuropathy(ies) since the date of the claim in August 2010, to include diabetic peripheral neuropathy(s). Please specifically state whether the Veteran has a current diagnosis of diabetic peripheral neuropathy in the right or left upper extremity. If not, please reconcile medical evidence of record noting a diagnosis of diabetic neuropathy. See, e.g., medical evidence from Fort Walton Beach Medical Center which noted peripheral neuropathy secondary to diabetes (VBMS entry titled "Medical Treatment Record Government Facility" on 07/31/2018). (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the right and left upper extremity peripheral neuropathy(ies) was/were CAUSED or AGGRAVATED by the Veteran's service-connected Type II diabetes mellitus. *Any increase/aggravation is sufficient, permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). *Note to examiner: To ensure that the correct legal standard is applied, which is essential for adjudication of this claim, the opinion MUST BE STATED IN TERMS OF whether the disorder was CAUSED or AGGRAVATED by the service-connected disorder. (c) If the answer to (b) is negative, provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed right and left upper extremity peripheral neuropathy(ies) onset during service, manifested within one year after service separation, or is otherwise etiologically related to service, to include exposure to herbicide agents during service. Note: VA has conceded the Veteran's in-service exposure to herbicide agents. In answering these questions, the VA examiner should consider the Veteran's lay statements. The examiner should provide a complete rationale for each opinion. Medical and/or scientific literature cited by the examiner should be adequately discussed and correlated to the Veteran's diagnoses and symptomatology. 6. Obtain an addendum opinion from an appropriately qualified VA examiner (other than the examiner who conducted the January 29, 2020 VA Male Reproductive System Conditions examination) regarding the nature and etiology of the Veteran's erectile dysfunction. All clinical findings should be reported in detail and correlated to a specific diagnosis(es). The claims file, and a copy of this Remand, must be made available to, and be reviewed by, the examiner. The examiner's review of the body of this Remand is recommended to assist in avoiding errors that have rendered previous VA opinions inadequate. *The need for another examination(s) is left to the discretion of the medical professional offering the addendum opinion. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a complete review of the claims file, the examiner is asked to respond to the following: (a) Identify all currently diagnosed erectile disorders since the date of the claim in August 2010. (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the erectile disorder(s) was CAUSED or AGGRAVATED by the Veteran's service-connected diabetes mellitus, Type II. (c) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the erectile disorder(s) was CAUSED or AGGRAVATED by the Veteran's service-connected hypertension. *Any increase/aggravation is sufficient, permanent aggravation is NOT required. See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (permanent worsening is not a requirement for secondary service connection of a non-service-connected injury or disease). *Note to examiner: To ensure that the correct legal standard is applied, which is essential for adjudication of this claim, the opinion MUST BE STATED IN TERMS OF whether the disorder was CAUSED or AGGRAVATED by the service-connected disorder. (c) If the answer to (b) and (c) are negative, provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the currently diagnosed erectile disorder(s) onset during service or is otherwise etiologically related to service. In answering these questions, the VA examiner should consider the Veteran's lay statements. The examiner should provide a complete rationale for each opinion. Medical and/or scientific literature cited by the examiner should be adequately discussed and correlated to the Veteran's diagnoses and symptomatology. 7. Thereafter, ensure that the examiner has substantially responded to the questions posed by the Board, and if not, take corrective action. 8. After completing any additional development deemed necessary, readjudicate the remanded claims. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Farrell 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.