Citation Nr: 21029415 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 15-40 626 DATE: May 13, 2021 ORDER Entitlement to service connection for a right elbow disability is denied. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for erectile disorder is remanded. Entitlement to service connection for a gastrointestinal disorder is remanded. Entitlement to service connection for a pulmonary disorder is remanded. Entitlement to service connection for a skin disability is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. FINDING OF FACT The preponderance of the probative evidence is against finding that a right elbow disability was demonstrated during or is related to the Veteran's active duty service, including due to herbicide agent exposure, or that it was caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for a right elbow disability have not been met. 38 U.S.C. §§ 1110, 1116, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1963 to October 1965. The Veteran has confirmed service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2011 rating decision by the Department of Veterans Affairs (VA). This case was remanded in August 2016, October 2017, and October 2020 for further development; it has since been re-assigned to the undersigned. In light of Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has recharacterized the issue of service connection for chronic obstructive pulmonary disease (COPD) to encompass any pulmonary disorder, to include chronic dyspnea on exertion. Service Connection for Right Elbow Disability The Veteran contends that he has a right elbow disability that is related to his military service. The Board notes that the Veteran's claim was originally submitted as a claim for "tendonitis," but as was discussed at length in the October 2020 Board remand, the evidence indicated that this was a reference to a right elbow disability, diagnosed by his VA treatment providers as lateral epicondylitis. The issue was therefore recharacterized to better represent the Veteran's intended claim. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish entitlement to service connection for a disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during servicethe so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation of a disability by a service-connected disability. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board also acknowledges that the Veteran is presumed to have been exposed to herbicide agents during his military service in Vietnam. VA regulations have established a presumption of service connection for certain diseases for veterans who service in the Republic of Vietnam and were exposed to herbicide agents; that list of diseases does not, however, include tendonitis or epicondylitis. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). Service connection based on exposure to herbicide agents may still be established on a direct basis when there is probative medical evidence of actual, direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran's service treatment records are silent for any diagnosis or treatment related to the right elbow, and the Veteran has not actually asserted that he incurred any right elbow injury or other tendonitis-related injury in service. The Veteran does have a current diagnosis of a right elbow disability. The Veteran's VA treatment records show that he has been diagnosed with lateral epicondylitis of the right elbow. In April 2007, he reported that he had been told he had tendonitis due to the repetitive type of work he does with his arms on the farm. The preponderance of the evidence does not establish, however, that it is as likely as not that his left elbow disability was incurred in or related to service, or that it has been caused or aggravated by any service-connected disability. A VA medical opinion on tendonitis and arthritis was obtained in November 2016. The VA examiner found that the service treatment records were silent for any tendinitis or arthritis complaints, and that significant factors in the development of tendinitis and arthritis on the weight-bearing joints was obesity and aging. He wrote that diabetes has not been known to play a direct role in the initiation or exacerbation of tendinitis or arthritis. He concluded that it was less likely as not that the Veteran's tendinitis and arthritis was due to his military service duties or due to diabetes. An October 2017 VA medical opinion was obtained which found that the Veteran's tendonitis, as well as other disorders, was not referenced in the claims file review, and was a very common complaint amongst the population and general and tended to be more prevalent with the passage of time. Because this examination did not focus on the Veteran's diagnosis of right elbow lateral epicondylitis, the Board requested that a new VA opinion be obtained. An addendum VA medical opinion was obtained in November 2019. The VA examiner reviewed the VA treatment records and related medical literature, but found that the Veteran's lateral epicondylitis was not the result of his presumed exposure to herbicide agents in service. She explained that lateral epicondylitis, also known as "tennis elbow," was a tendinopathy injury involving the extensor muscles of the forearm, and that any activity that over-stresses the involved tendon could cause the disorder. She explained that the Veteran's occupation and active gardening increased his risk for lateral epicondylitis, and that it was not a disorder that was related to herbicide exposure. An additional addendum VA opinion was obtained in February 2021. The examiner stated that medical records indicate the Veteran was diagnosed with right elbow lateral epicondylitis in April 2007. There were no medical records available until 2007, which was more than 40 years after the Veteran was discharged from service. In addition, the Veteran's record reported "heavy equipment operator" and "gardening" as his usual activity, and reiterated the prior examiner's explanation that his occupation and active gardening increased his risk of lateral epicondylitis. The examiner explained that any activity that overstresses the involved tendon can cause the disorder which include repetitive work, gardening, tennis, and golf. The examiner found no evidence available in medical records indicating the Veteran developed this condition during service. She wrote that since the Veteran's occupation and activities after discharge from service involve the overuse of his elbow, his disability is likely caused by his overuse of elbow due to his post-discharge occupation and less likely cause by military service. The examiner applied the similar reasoning to her conclusion that the Veteran's service-connected diabetes mellitus did not cause or aggravate his right elbow disability, also stating that there was no evidence available in medical literature supporting that diabetes mellitus could cause or aggravate this disability. The Board finds the November 2019 and February 2021 medical opinions to be adequate to decide this issue, as they were was based on an accurate understanding of the Veteran's medical history, they addressed all reasonable contentions and questions posed by the Board, and were supported by adequate rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The VA examiners found no relationship between the Veteran's right elbow disorder and service, including herbicide agent exposure, or between this disorder and diabetes mellitus, and provided thorough explanations for why it was more likely related to physical activities in the many years after service. There are no contradictory medical opinions of record which came to a different finding than those of these VA medical opinions. The Veteran has not actually provided any argument for why he believes that his right elbow disability is related to service. He has not asserted that his right elbow problems began in service, and in a November 2007 private treatment record, the Veteran reported that he his right elbow problems had only started a year or so previously. Nevertheless, while the Veteran may believe that his right elbow disability was caused by his military service, including exposure to herbicide agents, his assertion on the etiology of his condition is less probative than the findings of a qualified, expert medical examiner. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this case, the Veteran's assertion is not probative medical evidence towards such a complex question as the etiology of lateral epicondylitis of the right elbow, and it is outweighed by the opinion of the VA examiner. In sum, the evidence preponderates against finding entitlement to service connection for a right elbow disorder. The preponderance of the competent and probative medical evidence shows that the Veteran was not diagnosed with right elbow epicondylitis until many years after his separation from service, it has not been found to be related to service, and the disorder has not been found by any competent and probative medical evidence to be related to service or to a service-connected disability. The preponderance of the probative and competent evidence therefore weighs against the claim, and the claim is denied. In reaching this determination, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the claim, the doctrine is not for application. See 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. Service connection for hypertension is remanded. In the October 2020 remand, the Board noted that the November 2016 VA examiner stated that Veteran's hypertension could be related to disabilities that are now service-connected. Specifically, the examiner stated that the Veteran's cardiovascular disease and renal disease could be contributing factors to the Veteran's hypertension. The Veteran is currently service-connected for coronary artery disease and chronic kidney disease. An addendum VA opinion was obtained in February 2021. The examiner opined that the Veteran's hypertension was less likely than not caused or aggravated by chronic kidney disease or coronary artery disease. He stated that the Veteran was diagnosed with hypertension several years before he was diagnosed with chronic kidney disease or coronary artery disease. In addition, hypertension is not caused by secondary causes like chronic kidney disease or coronary artery disease and hence, the Veteran's hypertension is not caused or aggravated by either. The Board finds this opinion inadequate for appellate review. It is vague and conclusory, and does not reconcile the November 2016 VA examiner's statement that the Veteran's cardiovascular disease and renal disease could be contributing factors to the Veteran's hypertension. As such, the Board finds that an addendum VA opinion with a more detailed rationale is needed. Further, the Board finds that remand is also appropriate to obtain an addendum opinion concerning whether obesity is an "intermediate step" between the service-connected diabetes mellitus and the diagnosed hypertension. The Board notes that obesity is not a disability for purposes of VA benefits; hence, it cannot be service connected on a direct basis. See Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018). However, indirect secondary service connection can be granted with obesity acting as an "intermediate step." See VAOPGCPREC 1-2017 (Jan. 6, 2017). Specifically, a grant is warranted (1) if the service-connected disability caused the Veteran to become obese, (2) if obesity was a substantial factor in causing a subsequent disability, and (3) if the subsequent disability would not have occurred but for obesity. Id. The November 2016 VA examination contains the examiner's conclusion that obesity is a contributing factor to the Veteran's hypertension. The Veteran is currently service-connected for diabetes mellitus. On remand, an addendum opinion is required to help inform the Board's decision on whether obesity is an intermediate step between the Veteran's service-connected diabetes mellitus and his currently diagnosed hypertension. 2. Service connection for erectile disorder is remanded. In the October 2020 remand, the Board noted that the November 2016 VA examiner stated that Veteran's erectile dysfunction could be related to disabilities that are now service-connected. Specifically, the examiner stated that the Veteran's cardiovascular disease and diabetes mellitus could be contributing factors to the Veteran's erectile disorder. The Veteran is current service-connected for coronary artery disease and diabetes mellitus. An addendum VA opinion was obtained in February 2021. The examiner opined that the Veteran's erectile dysfunction was less likely than not caused or aggravated by coronary artery disease or chronic kidney disease. He stated that there are several factors that could [cause] this condition, like hypertension, obesity, tobacco use, and aging in addition to diabetes. As the Veteran has a history of chronic hypertension and obesity, his erectile dysfunction is likely caused by his chronic hypertension, obesity, and aging. The Board finds this opinion inadequate for appellate review. It is vague and conclusory, and does not reconcile the November 2016 VA examiner's statement that the Veteran's cardiovascular disease could be a contributing factor to the Veteran's erectile disorder. Further, the examiner does state that diabetes could have caused this condition, which the Veteran is service-connected for. As such, the Board finds that an addendum VA opinion with a more detailed rationale is needed. Additionally, the examiner notes that hypertension could be a contributing factor to the Veteran's erectile disorder. The issue of service connection for hypertension is being remanded herein. As such, the issue of service connection for erectile disorder is inextricably intertwined with issue of service connection for hypertension. Further, the Board finds that remand is also appropriate to obtain an addendum opinion concerning whether obesity is an "intermediate step" between the service-connected diabetes mellitus and the diagnosed erectile disorder. See Marcelino, 29 Vet. App. at 158; VAOPGCPREC 1-2017. The VA examination contains the examiner's conclusion that obesity is a cause of the Veteran's erectile disorder. The Veteran is currently service-connected for diabetes mellitus. On remand, an addendum opinion is required to help inform the Board's decision on whether obesity is an intermediate step between the Veteran's service-connected diabetes mellitus and his currently diagnosed erectile disorder. 3. Service connection for a gastrointestinal disorder is remanded. In the October 2020 remand, the Board noted that the November 2016 VA examiner stated that Veteran's gastrointestinal disorder could be related to a disability that is now service-connected. Specifically, the examiner stated that the Veteran's renal disease could be a contributing factor to the Veteran's gastrointestinal disorder. The Veteran is currently service-connected for chronic kidney disease. An addendum VA opinion was obtained in February 2021. The examiner opined that the Veteran's gastrointestinal disorder was less likely than not caused or aggravated by chronic kidney disease. He stated that the Veteran has diagnoses of GERD with hiatal hernia and Barrett's esophagus. GERD is caused by weakening or abnormal relaxation of lower esophageal sphincter making the backlash of acid that irritates the lining of esophagus. There were several risk factors for development of GERD and hiatal hernia including smoking, eating large meals or eating late at night, eating certain foods, drinking certain beverages, and obesity. A review of the Veteran's medical records notes the Veteran has a history of obesity, smoking, and alcohol intake and these are the likely factors for development of the Veteran's GERD. There is no evidence available in medical literature indicating chronic kidney disease could cause or increase the risk for development of GERD. The Board finds this opinion inadequate for appellate review. It did not reconcile the November 2016 VA examiner's statement that the Veteran's chronic kidney disease could be a contributing factor to the Veteran's gastrointestinal disorder. As such, the Board finds that an addendum VA opinion with a more detailed rationale is needed. Further, the Board finds that remand is also appropriate to obtain an addendum opinion concerning whether obesity is an "intermediate step" between the service-connected diabetes mellitus and the diagnosed gastrointestinal disorder. See Marcelino, 29 Vet. App. at 158; VAOPGCPREC 1-2017. The February 2021 VA examination contains the examiner's conclusion that obesity is a cause of the Veteran's gastrointestinal disorder. The Veteran is currently service-connected for diabetes mellitus. On remand, an addendum opinion is required to help inform the Board's decision on whether obesity is an intermediate step between the Veteran's service-connected diabetes mellitus and his currently diagnosed gastrointestinal disorder. 4. Service connection for a pulmonary disorder is remanded. In the October 2020 remand, the Board noted that the November 2018 VA examiner stated that Veteran's COPD could be related to a disability that is now service-connected. Specifically, the examiner stated that "per medical literature, some of the most cases of dyspnea result from heart failure and myocardial ischemia." The Veteran is currently service-connected for coronary artery disease. An addendum VA opinion was obtained in February 2021. The examiner opined that the Veteran's COPD was less likely than not caused or aggravated by coronary artery disease. He stated that on review of medical records, no evidence was available that the Veteran has a diagnosis of COPD. In addition, the most common cause of COPD is smoking. The Veteran has a history of smoking. Both COPD and coronary artery disease could cause symptoms of shortness of breath, but physiology of development of shortness of breath caused by COPD and coronary artery disease is different and coronary artery disease does not cause or aggravate COPD. As noted above, pursuant to Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Board has recharacterized the issue of service connection for COPD to encompass any pulmonary disorder, to include chronic dyspnea on exertion. The Board finds this opinion inadequate for appellate review. It is vague and conclusory, and does not reconcile the November 2018 VA examiner's statement that cardiovascular disease could be a contributing factor to the Veteran's pulmonary disorder. Further, the examiner states that there is no diagnosis on record of COPD, but then provided an opinion based on a diagnosis of COPD, rather than the Veteran's diagnosed dyspnea. As such, the Board finds that an addendum VA opinion with a more detailed rationale is needed. 5. Service connection for a skin disability is remanded. In the October 2020 remand, the Board noted that the November 2016 VA examiner provided an opinion regarding the relationship between the Veteran's skin disability and his active duty service. The VA examiner based his medical nexus opinion on the fact that the Veteran was not diagnosed with a skin disability until 2004, nearly 40 years after his separation from active duty. However, a review of the Veteran's private treatment records shows complaints of skin rash and a diagnosis of skin lesions dating back to 1990, 25 years after the Veteran's separation from active duty service. The Board remanded the issue for clarification on whether this fact changes the VA examiner's opinion. Further, in the October 2020 remand, the Board noted that the November 2016 VA direct service connection opinion was based on a diagnosis of actinic keratoses. Since then, the Veteran has been diagnosed with squamous cell carcinoma. A November 2018 secondary service connection VA opinion was also based on a diagnosis of actinic keratosis, prior to the diagnosis of squamous cell carcinoma. The Board remanded the issue for clarification on whether the new diagnosis within the appellate period impacts the VA examiners' opinions. An addendum opinion was obtained in February 2021. The examiner stated that upon review of medical records, it was noted that the Veteran was diagnosed with squamous cell carcinoma of skin in 2019 and actinic keratosis around 2015. The November 2016 medical opinion indicated that the Veteran had a skin condition related to actinic keratosis which is a pre-cancerous condition caused by excessive sun exposure and damage of the skin which could increase the risk of development of skin cancer. On review of medical records, there was no evidence available indicating the Veteran developed or was diagnosed with actinic keratosis in the 1990s and even if the Veteran carried the diagnosis of actinic keratosis in the 1990s, it was likely caused by sun exposure and not related to any other skin condition related to the military service, and hence, [the examiner] would not support the change in VA medical opinion dated November 2016. The Board finds this opinion inadequate for appellate review. It is conclusory and focuses on the lack of a diagnosis of actinic keratosis in 1990 but does not actually address the post-service complaints of skin rash and a diagnosis of skin lesions. Further, it does not specifically address any potential relationship between the 1990 medical records and the Veteran's recent diagnosis of squamous cell carcinoma. As such, the Board finds that an addendum VA opinion with a more detailed rationale is needed. 6. Service connection for OSA is remanded. In the October 2020 remand, the Board noted that the October 2010 and November 2016 VA examiners provided opinions that the Veteran's OSA was not caused by his service-connected diabetes mellitus, but did not provide opinions regarding aggravation. An addendum VA opinion was obtained in February 2021. The examiner opined that the Veteran's OSA was less likely than not caused or aggravated by his service-connected diabetes mellitus. He stated that studies show that obesity is a common cause of sleep apnea, hence the Veteran's OSA is likely caused by obesity. In addition, there is no evidence available in medical literature indicating diabetes could cause or aggravate OSA. The Board finds this opinion inadequate for appellate review. It is vague and conclusory. As such, the Board finds that an addendum VA opinion with a more detailed rationale is needed. Further, the Board finds that remand is also appropriate to obtain an addendum opinion concerning whether obesity is an "intermediate step" between the service-connected diabetes mellitus and the diagnosed OSA. See Marcelino, 29 Vet. App. at 158; VAOPGCPREC 1-2017. The VA examination contains the examiner's conclusion that obesity is a cause of the Veteran's OSA. The Veteran is currently service-connected for diabetes mellitus. On remand, an addendum opinion is required to help inform the Board's decision on whether obesity is an intermediate step between the Veteran's service-connected diabetes mellitus and his currently diagnosed OSA. The matters are REMANDED for the following action: 1. The AOJ should obtain updated VA and non-VA treatment records. 2. The AOJ should obtain an addendum opinion as to the nature and etiology of the Veteran's hypertension. The examiner should review the file and provide a complete rationale for all opinions expressed. An examination or telehealth interview should be scheduled only if deemed needed by the examiner. Based on a review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (i) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's hypertension was either caused or aggravated by the Veteran's service-connected coronary artery disease and/or service-connected chronic kidney disease. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran's statements regarding the onset and persistence of his symptoms. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation. The examiner must discuss the November 2016 examiner's statement that the Veteran's cardiovascular disease and renal disease could be contributing factors to the Veteran's hypertension. (ii) Do any of the Veteran's service-connected disabilities, such as diabetes mellitus, result in obesity, and is this obesity an "intermediate step" between the disorder and the currently diagnosed hypertension? The examiner must discuss the November 2016 examiner's statement that obesity is a contributing factor to the Veteran's hypertension. 3. The AOJ should obtain an addendum opinion as to the nature and etiology of the Veteran's erectile disorder. The examiner should review the file and provide a complete rationale for all opinions expressed. An examination or telehealth interview should be scheduled only if deemed needed by the examiner. Based on a review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (i) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's erectile disorder was either caused or aggravated by the Veteran's service-connected diabetes mellitus, service-connected coronary artery disease, and/or (as of yet) nonservice-connected hypertension. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran's statements regarding the onset and persistence of his symptoms. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation. The examiner must discuss the November 2016 examiner's statement that the Veteran's cardiovascular disease and diabetes mellitus could be contributing factors to the Veteran's erectile disorder and the February 2021 examiner's statement that the Veteran's hypertension could be a contributing factor to his erectile disorder. (ii) Do any of the Veteran's service-connected disabilities, such as diabetes mellitus, result in obesity, and is this obesity an "intermediate step" between the disorder and the currently diagnosed erectile disorder? The examiner must discuss the February 2021 examiner's statement that obesity could be a contributing factor to the Veteran's erectile disorder. 4. The AOJ should obtain an addendum opinion as to the nature and etiology of the Veteran's gastrointestinal disorder. The examiner should review the file and provide a complete rationale for all opinions expressed. An examination or telehealth interview should be scheduled only if deemed needed by the examiner. Based on a review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (i) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's gastrointestinal disorder was either caused or aggravated by the Veteran's service-connected chronic kidney disease. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran's statements regarding the onset and persistence of his symptoms. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation. The examiner must discuss the November 2016 examiner's statement that the Veteran's renal disease could be a contributing factor to the Veteran's gastrointestinal disorder. (ii) Do any of the Veteran's service-connected disabilities, such as diabetes mellitus, result in obesity, and is this obesity an "intermediate step" between the disorder and the currently diagnosed gastrointestinal disorder? The examiner must discuss the February 2021 examiner's statement that obesity could be a contributing factor to the Veteran's gastrointestinal disorder. 5. The AOJ should obtain an addendum opinion as to the nature and etiology of the Veteran's pulmonary disorder. The examiner should review the file and provide a complete rationale for all opinions expressed. An examination or telehealth interview should be scheduled only if deemed needed by the examiner. Based on a review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (i) Please identify, by diagnosis, all pulmonary disabilities present during the appeal period. (ii) If no separate pulmonary disorder is diagnosed, does the Veteran have respiratory symptoms, such as dyspnea, which are symptoms of his service-connected coronary artery disease? (iii) For each pulmonary disability diagnosed, whether it is at least as likely as not (50 percent or greater probability) that such disability was either caused or aggravated by the Veteran's service-connected coronary artery disease. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran's statements regarding the onset and persistence of his symptoms. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation. The examiner must discuss the November 2018 examiner's statement that cardiovascular disease could be a contributing factor to the Veteran's pulmonary disorder. 6. The AOJ should obtain an addendum opinion as to the nature and etiology of the Veteran's skin disability. The examiner should review the file and provide a complete rationale for all opinions expressed. An examination or telehealth interview should be scheduled only if deemed needed by the examiner. Based on a review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (i) Please identify, by diagnosis, all skin disabilities present during the appeal period, to include actinic keratosis and squamous cell carcinoma. (ii) For each skin disability diagnosed, whether it is at least as likely as not (50 percent or greater probability) that such disability was either incurred in or otherwise related to the Veteran's military service? Please explain why. The examiner must discuss the Veteran's 1990 medical records noting complaints of skin rash and a diagnosis of skin lesions. 7. The AOJ should obtain an addendum opinion as to the nature and etiology of the Veteran's obstructive sleep apnea (OSA). The examiner should review the file and provide a complete rationale for all opinions expressed. An examination or telehealth interview should be scheduled only if deemed needed by the examiner. Based on a review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: (i) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's OSA was either caused or aggravated by the Veteran's service-connected diabetes mellitus. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran's statements regarding the onset and persistence of his symptoms. The opinion must address whether the disability increased in severity beyond its natural progression (i.e., was aggravated). If aggravation is found, the examiner should identify to the extent possible the baseline level of disability prior to the aggravation. (ii) Do any of the Veteran's service-connected disabilities, such as diabetes mellitus, result in obesity, and is this obesity an "intermediate step" between the disorder and the currently diagnosed OSA? (Continued on the next page) The examiner must discuss the February 2021 examiner's statement that obesity is the likely cause of the Veteran's OSA. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. Kerner, 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.