Citation Nr: 21031630 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 17-52 897 DATE: May 24, 2021 ORDER Entitlement to service connection for gastroesophageal reflux disease (GERD) is granted. Entitlement to service connection for hypertension (also claimed as high blood pressure) is granted. Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for a mental health disorder, diagnosed as posttraumatic stress disorder (PTSD) and major depressive disorder, is granted. Entitlement to service connection for hyperlipidemia is denied. REMANDED Entitlement to service connection for a nasal disorder (claimed as sinusitis) is remanded. Entitlement to service connection for insomnia is remanded. Entitlement to service connection for right ear hearing loss is remanded. Entitlement to an initial evaluation in excess of 20 percent for degenerative arthritis of the lumbar spine claimed as degenerative disc L5-S1 is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's GERD had its onset during a period of qualifying service. 2. The Veteran's hypertension had its onset during a period of qualifying service. 3. The Veteran's obstructive sleep apnea had its onset during a period of qualifying service. 4. The Veteran's tinnitus had its onset during a period of qualifying service. 5. The Veteran's PTSD and major depressive disorder is related to a verified in-service stressor that occurred during a period of qualifying service. 6. The Veteran's hyperlipidemia is a laboratory finding and not a disability for Department of Veterans Affairs (VA) compensation purposes. CONCLUSIONS OF LAW 1. The criteria for service connection for GERD have been met. 38 U.S.C. §§ 101, 1110; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303. 2. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 101, 1110; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303. 3. The criteria for service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 101, 1110; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303. 4. The criteria for service connection for tinnitus have been met. 38 U.S.C. §§ 101, 1110; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303. 5. The criteria for service connection for a mental health disorder, diagnosed as PTSD and major depressive disorder, have been met. 38 U.S.C. §§ 101, 1110; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.304, 4.125. 6. The criteria for service connection for hyperlipidemia have not been met. 38 U.S.C. §§ 101, 1110, 1131; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the New York Army National Guard from 1981 to 2011, when he was assigned to the Retired Reserve. He had qualifying service from January 1982 to April 1982 (initial active duty for training) and from April 1987 to February 2011 (full-time Active Guard Reserve (AGR) service under 32 C.F.R. § 502(f), which is active duty for training (ACDUTRA) for VA compensation purposes). See DD 214s, NGB Form 22, and related orders; 38 U.S.C. § 101(21)-(24); 38 C.F.R. § 3.6. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision by VA. A hearing was held before the undersigned Veterans Law Judge in October 2020. A transcript of the hearing is of record. The Veterans Law Judge noted on the record that the Veteran was able to address the financial concerns he previously raised to some extent, and that he was going to talk with his representative after the hearing and decide whether to put in an advance on the docket request, along with more information as to the financial issues. The Veteran has not submitted such a request. In addition, the Veterans Law Judge held the record open for a 90-day period for the submission of additional evidence. Thereafter, the Veteran submitted evidence for which there is an automatic waiver of initial agency of original jurisdiction (AOJ) review, along with an actual waiver. Initially, the Veteran was not provided a VA examination for his hyperlipidemia claim. The duty to assist includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim. This development is necessary if the evidence of record: (1) contains competent evidence that the claimant has a current disability or persistent or recurrent symptoms of a disability; (2) establishes that the claimant suffered an event, injury, or disease in service, or has a presumptive disease or symptoms of such a disease manifesting during an applicable presumptive period; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service, or with another service-connected disability; but (4) does not contain sufficient competent medical evidence to decide the claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In a March 2017 written appellate brief, the Veteran's representative argued that a VA examination was needed to determine whether the Veteran had a diagnosable disorder as a result of his hyperlipidemia, citing to online medical database evidence noting that hyperlipidemia can significantly increase a person's risk of developing cardiovascular disease, including peripheral artery disease. In so doing, he noted that in-service treatment records document symptoms of heart palpitations, abdominal pain, and leg pain. Nevertheless, neither the in-service treatment records nor post-service treatment records reflect that the Veteran has such a diagnosis or persistent or recurrent symptoms suggesting such a disease process. The December 2004 VA treatment record shows the Veteran's reported abdominal pain was resolved with omeprazole, which is a medication for treatment of his GERD. As noted by the representative, a September 2010 VA treatment record does show a history of heart palpitations the year prior; the Veteran reported that he was told that everything was ok after a medical work up. The September 2009 private treatment record related to the actual treatment does show reported heart palpitations, with negative diagnostic testing. The Veteran reported at that time that he believed the symptom was related to anxiety, and he has received no related heart disorder diagnosis. The referenced November 2010 VA treatment record and October 2015 private medical opinion from Dr. O.N. indicate that the Veteran's leg pain is part of neurological manifestations of his service-connected lumbar spine disability, rather than peripheral artery disease. In this decision, the Board has granted service connection for GERD, hypertension, and a mental health disorder on an in-service onset basis, and the Veteran's lumbar spine disability claim (that will also address any potentially associated lower extremity neurological manifestations) remains on appeal. Based on the foregoing, the Board finds that a VA examination or medical opinion is not necessary for the hyperlipidemia claim. Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable. 38 U.S.C. § 101(2); 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes active duty, any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C. § 101(24); 38 C.F.R. §§ 3.6(a)-(d). Full-time National Guard duty under 32 C.F.R. § 502 is considered ACDUTRA for VA compensation purposes. 38 U.S.C. § 101(22)(C). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As hypertension and tinnitus are considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) and Fountain v. McDonald, 27 Vet. App. 258 (2015) (holding that presumptive provisions of 38 C.F.R. § 3.309(a) include tinnitus, at a minimum where there is evidence of acoustic trauma, as an organic disease of the nervous system). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hypertension and tinnitus, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The presumption is not applicable to claims based on periods of ACDUTRA or INACDUTRA unless veteran status has been established for that period of service. See Smith v. Shinseki, 24 Vet. App. 40, 47 (2010); Hill v. McDonald, 28 Vet. App. 243, 252 (2016). Here, the claimant has achieved veteran status for the service period at issue (1987 to 2011) based on the award of service connection for the lumbar spine disability and is accordingly referred to as such in this decision. Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The Board notes as a preliminary matter that the Veteran explained during the October 2020 hearing that he was permitted to use VA as a primary treatment provider during his AGR service because of the significant distance to the closest military facility. As such, many of the Veteran's in-service treatment records discussed in this decision are from VA or non-VA treatment providers, rather than military facilities. GERD In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for GERD. The Veteran has contended that his GERD began during his period of qualifying service from 1987 to 2011. See March 2017 written appellate brief; October 2020 Bd. Hrg. Tr. The Veteran's service treatment records show that his relevant body systems were found to be normal on multiple examinations, and he also denied a history of relevant symptoms on the corresponding reports of medical history and annual medical certificates dated from 1981 to 2003. A September 2004 VA treatment record shows that he reported a history of episodic epigastric pains for about two years with a two-month exacerbation, worse at night and relieved with tums. The assessment included chronic abdominal pain, and he was started on a trial of omeprazole/prilosec. See also March 2003 service treatment record (similar complaint with assessment to rule out GERD). The Veteran continued to take that medication thereafter, which was noted in the treatment records to be for GERD and provide relief of his abdominal pain. See, e.g., VA treatment records from May 2006 and September 2010. The service treatment records also show that the Veteran reported having acid reflux, as well as the continued use of omeprazole at the time of the January 2011 retirement examination. The examiner noted a diagnosis of GERD treated with PPI (proton pump inhibitor) in the summary section, as well as in the corresponding examination report. The post-service evidence shows that the Veteran has a current GERD diagnosis for which he has continued to be treated with the same medication. See, e.g., private treatment records from March 2015 and September 2015 (close in time to claim), May 2016, November 2017, October 2018, and April 2019 (noted intermittent GERD for many years). In a September 2015 VA examination requested by the Veteran to support his claim, a VA physician noted review of in-service and post-service medical records (also noting review of the claims file in another section of the reports provided that day) and indicated that the Veteran began taking omeprazole while in service for GERD that he continued to take it for his current GERD symptoms with relief, confirming the ongoing nature of the disorder. There is no medical opinion to the contrary. Based on the foregoing, the Board concludes that the Veteran's GERD had its onset in service, and as such, service connection is warranted for the disorder. Hypertension In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for hypertension. The Veteran has contended that his hypertension began around 2008, during his period of qualifying service from 1987 to 2011. See March 2017 written appellate brief; October 2020 Bd. Hrg. Tr. The Veteran's service treatment records show that his relevant body systems were found to be normal on multiple examinations, and he also denied a history of relevant symptoms on the corresponding reports of medical history and annual medical certificates dated from 1981 to 2003. A July 2006 VA treatment record shows that the Veteran's treatment provider started him on lisinopril based on slightly elevated blood pressure readings, and an October 2010 VA treatment record to reestablish primary care shows an assessment including hypertension, with the Veteran reporting taking his spouse's medication because he ran out of his own. A March 2007 private treatment record shows that hypertension was added as a new problem. The service treatment records also show that the Veteran reported a history of high blood pressure at the time of the January 2011 retirement examination, and the examiner noted a diagnosis of hypertension with medication recommended/not taking medication as advised in the summary sections, as well as in the corresponding examination report. The post-service evidence shows that the Veteran has a current hypertension diagnosis for which he has continued to be treated with medication. See, e.g., private treatment records from 2012 to 2014 (historical treatment), March 2015 and September 2015 (close in time to claim), November 2017, October 2018, November 2019, and July 2020. In a September 2015 VA examination requested by the Veteran to support his claim, a VA physician noted review of the claims file, also noting elevated blood pressure readings from the past several months, as well as those taken on the day the opinion was provided. The examiner determined that the Veteran began taking antihypertensive medications while in service for a hypertension diagnosis that he had taken since that time, confirming the ongoing nature of the disorder. There is no medical opinion to the contrary. Based on the foregoing, the Board concludes that the Veteran's hypertension had its onset in service, and as such, service connection is warranted for the disorder. Obstructive Sleep Apnea In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for sleep apnea. The Veteran has contended that he had in-service symptoms observed by his spouse beginning during his period of qualifying service from 1987 to 2011 that were early manifestations of his now diagnosed sleep apnea. He has indicated that he did not seek a sleep study in service because he did not have knowledge of sleep apnea itself and did not think anything of the symptoms at that time. See October 2020 Bd. Hrg. Tr. The Veteran's service treatment records show that his relevant body systems were found to be normal on multiple examinations, and he also denied a history of relevant symptoms on the corresponding reports of medical history and annual medical certificates dated from 1981 to 2003. He did later report trouble sleeping, including at the time of the January 2011 separation examination, as detailed in his separate insomnia claim. In a March 2015 post-service initial appointment with Dr. J.F., it was noted that the Veteran had symptoms over the past several years that he apparently had not brought up for a discussion, including snoring, non-restorative sleep, daytime somnolence, disturbed sleep, and insomnia. Dr. J.F. noted that the symptoms might be attributable to untreated obstructive sleep apnea, especially with the heavy snoring, non-restorative sleep, and daytime somnolence, and referred the Veteran for a diagnostic polysomnogram. In an April 2015 VA walk-in psychiatric appointment about a week later, the Veteran reported that his spouse told him he had sleep apnea, causing him to research on the internet and wonder if it was the cause of his insomnia. Parenthetically, the Board notes that this report supports his contention that he was not aware that he had such a problem for which he should have sought out a sleep study earlier. That same month, the Veteran was diagnosed with obstructive sleep apnea on the private sleep study. The pre-testing questionnaire from his spouse shows that she had observed symptoms including loud snoring with breathing disturbances and twitching of the legs and feet that had been ongoing for approximately 15 years (i.e., around 2000) and had progressively become worse. The Board notes that the Veteran's spouse is competent to report observable symptomatology and events, including her observations as to the Veteran's sleep problems. In addition, the Board finds there is no reason to doubt her as to her observation of such symptoms other than the lack of contemporaneous medical evidence, particularly given the Veteran's reports above. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). In a June 2015 disability benefits questionnaire and corresponding treatment record from that same day, Dr. J.F. noted that the Veteran had the disorder for approximately 15 years based on his symptomatology; however, in a September 2015 treatment record, he noted that he declined to write a nexus statement relating the symptoms to the Veteran's military service, suggesting that he should request such an opinion from VA doctors. In October 2015 private medical opinions, Dr. O.N., the Veteran's primary care provider, similarly determined that it was more likely than not that the Veteran's current disorder existed during his time in service but was never diagnosed. In an August 2016 private medical opinion, Dr. J.J. determined that it was more likely than not that the Veteran's sleep apnea developed during his military service based on the lay statements and recent medical literature. In so finding, he noted review of the Veteran's medical history, including in-service and post-service treatment records, and noted that since only a sleep study can diagnose the disorder, and his physical and laboratory exams were generally normal, he went undiagnosed until he had the 2015 sleep study. In an April 2018 medical opinion, Dr. J.J. noted that the in-service difficulties the Veteran experienced from pain due to his service-connected lumbar spine disability and now service-connected mental health disorder resulted in sleep disturbances. Although the 2015 treatment provider statements do not contain complete rationales, taken together, the determinations of the Veteran's treatment providers establish an association between his in-service symptoms and current sleep apnea, inasmuch and they believe the in-service symptoms represent early manifestations of the diagnosed disorder. In reviewing the treatment providers' findings in the context of the other evidence of record, the Board finds that their determinations are based on consideration of the Veteran's in-service history confirmed by the record and medical history as a patient, as well as current medical understanding. Therefore, the opinions are entitled to probative weight. There is no opinion to the contrary. In a September 2015 VA examination requested by the Veteran to support his claim, the examiner noted the reported history and current diagnosis without addressing the question of etiology. Based on the foregoing, the Board concludes that the Veteran's sleep apnea had its onset in service, and as such, service connection is warranted for the disorder. Tinnitus In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for tinnitus. The Veteran has contended that he has tinnitus that began in 2008, during his period of qualifying service from 1987 to 2011. See March 2017 written appellate brief; October 2020 Bd. Hrg. Tr. The Veteran's service treatment records show that his relevant body systems were found to be normal on multiple examinations, and he also denied a history of relevant symptoms on the corresponding reports of medical history and annual medical certificates dated from 1981 to 2003. January 2008 and April 2008 private treatment records show that the Veteran reported having tinnitus, and an October 2010 VA treatment record shows that he continued to have tinnitus and was told by his non-VA treatment provider that nothing could be done for it. The service treatment records also show that the Veteran was found to have tinnitus at the time of the January 2011 retirement examination. The post-service evidence shows that the Veteran has a current diagnosis of intermittent, recurring tinnitus. Charles v. Principi, 16 Vet. App. 370, 374 (2002) (noting that tinnitus is a type of disorder capable of lay observation and description); see also February 2016 VA examination report and August 2015 VA treatment record (close in time to claim) and McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (requirement of current disability satisfied when claimant has a disability at the time a claim for VA disability compensation is filed or at any point during pendency of that claim). During the August 2015 VA audiological consultation, the Veteran reported that he had a history of military noise exposure from qualification on the range every year. The February 2016 VA examiner determined that the Veteran's reports of cause and onset of tinnitus were inconsistent; however, the record shows that his reported history is consistent with the contemporaneous treatment records outlined above. During the October 2020 hearing, the Veteran again noted that he believed that his tinnitus began in 2008, and that the specialist that he was referred to told him that there was no cure for it. Based on the foregoing, there is an approximate balance of positive and negative evidence as to whether the Veteran's current tinnitus had its onset in service. Resolving reasonable doubt in favor of the Veteran, the claim is granted. Mental Health Disorder In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is warranted for PTSD and major depressive disorder. The Veteran has contended that he developed a mental health disorder as a result of his military service because he was located in New York City on September 11, 2001. He indicated that the day was difficult due to the circumstances, including the telephones going down and being unable to reach his pregnant spouse working in Manhattan, as well as being in lockdown and waiting to pick up his small children. He also indicated that he had recruited a number of soldiers that were activated around that time, and some of them did not come back, causing him feelings of guilt. See October 2015 written stressor statement; October 2020 Bd. Hrg. Tr. Regarding the claimed stressor, the Board takes judicial notice of the well-documented events of September 11, 2001, including the difficulties faced by individuals working and living in the city at that time attempting to reunite with their families and move to safe locations. The Veteran's service records confirm that he was in full-time AGR status as a recruiting and retention non-commissioned officer and located in New York City at that time. The birth certificates he submitted for his children for dependency benefit purposes also confirms that he had young children and his spouse was pregnant. Based on the foregoing, the Board finds that there is credible evidence to support the Veteran's reports that the claimed in-service stressor occurred. The Veteran's service treatment records show that he was found to be psychiatrically normal on multiple examinations, and he also denied a history of relevant symptoms on the corresponding reports of medical history and annual medical certificates dated from 1981 to 2003. He did later seek in-service treatment for mental health symptoms beginning around 2009 as a result of in-service events beginning with the reported stressor. For example, in an October 2010 VA psychosocial assessment, it was noted that the Veteran presented for care with problems including anxiety and terminal insomnia, and a positive PTSD screen was related to family event and the events of 9/11. The preliminary diagnosis was anxiety disorder NOS (not otherwise specified), depression NOS, and rule out PTSD. In a November 2010 VA treatment record, it was noted that since 9/11, he had reported hypervigilance around and avoidance of Manhattan and hypervigilance when airplanes flew above him, as well as reported fear about his pregnant spouse who was in Manhattan that day. He also reported ongoing symptoms of depression and anxiety at the time of the January 2011 separation examination. The post-service evidence shows that he has received PTSD and major depressive disorder diagnoses. In addition, the Board finds that the Veteran has PTSD and major depressive disorder that are related to the verified in-service stressor. In a September 2015 VA medical opinion, Dr. R.G.A. noted that the Veteran had been under his care since June 2015, and that he presented with symptoms consistent with PTSD, including a depressed mood and anxiety. In a September 2018 private medical opinion, Dr. Q.A.-S. noted that he had reviewed the claims file and evaluated the Veteran, including a standardized screening instrument for PTSD evaluation, and determined that an accurate psychiatric diagnostic formulation would involve PTSD and major depressive disorder. In so finding, he indicated that the Veteran clearly began experiencing symptoms of anxiety and depression while in military service, as evidenced by his recollections, written statements, and medical records. He further indicated that the Veteran's PTSD began in reaction to the events of September 11, 2001, and that there were no other factors that would otherwise explain the development of his psychiatric conditions. There is no opinion to the contrary. Based on the foregoing, the Board concludes that the Veteran's mental health disorder, diagnosed as PTSD and major depressive disorder, is related to his service, and as such, service connection is warranted for the disorder. Hyperlipidemia In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is not warranted for hyperlipidemia. The service treatment records and post-service evidence show that the Veteran has a history of hyperlipidemia, as well as current hyperlipidemia. See, e.g., December 2004 VA treatment record (in service notation of history of hyperlipidemia); private treatment records from November 2017 and February 2019. Hyperlipidemia, also referred to as high cholesterol, is "a general term for elevated concentrations of any or all of the lipids in the plasma, including hypertriglyceridemia, hypercholesterolemia, etc." Dorland's Illustrated Medical Dictionary, 891 (32nd ed. 2012). Hyperlipidemia and elevated cholesterol are laboratory findings and are not disabilities in and of themselves for VA compensation purposes. See 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities. They are, therefore, not appropriate entities for the rating schedule). The Board acknowledges that hyperlipidemia may be evidence of underlying disability or may later cause disability. In this case, however, the record does not establish that the Veteran has a resulting disability due to his hyperlipidemia for the same reasons detailed in the duty to assist portion of the decision above. Based on the foregoing, the evidence does not demonstrate a disability for which service connection may be granted. Therefore, the claim must be denied. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). REASONS FOR REMAND On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran's claims. Specifically, it appears that there may be outstanding treatment records for the right ear hearing loss and lumbar spine claims, as detailed in the directives below. Regarding the nasal disorder claim, the Veteran originally claimed the disorder as sinusitis. In a September 2015 VA examination requested by the Veteran to support his claim, a VA physician noted review of in-service and post-service medical records (also noting review of the claims file in another section of the reports provided that day) and determined that the Veteran did not have a current diagnosis of acute or chronic sinusitis. During the hearing, he testified that he started using flonase for "the allergies and the sinuses" beginning in early 2000 and that he still used that medication. The service treatment records show that he received treatment for sinus problems and seasonal allergies, and the post-service treatment records show a current diagnosis of allergic rhinitis, as detailed in the directives below. Based on the foregoing, including the Veteran's ongoing reports of allergy problems along with sinus problems, an additional VA medical opinion is needed to address the allergic rhinitis diagnosis. Regarding the insomnia claim, the record shows that the Veteran has reported insomnia problems both during and since service, as detailed in the directives below. The treatment records suggest that the reported insomnia is a symptom of the now service-connected mental health disorder, as opposed to a separately diagnosable disorder; however, a VA medical opinion is needed to decide such. Regarding the right ear hearing loss claim, the AOJ has conceded in-service noise exposure. The Veteran was provided a VA examination in February 2016 in which the examiner determined that it was not at least as likely as not that the current right ear hearing loss was caused by or a result of an event in military service. In so finding, she noted that the validity of the January 2011 retirement examination audiological findings were unreliable and that the current hearing loss did not resemble a noise-induced hearing loss configuration, suggesting an etiology other than military noise exposure. Although the examiner addressed questions related to the hearing loss, it is unclear if she considered the complete history of the development of the disorder, including the multiple other in-service audiological tests. In addition, the Veteran's representative indicated that his hearing loss could be related to potential ear damage from his in-service sinus problems. See March 2017 written appellate brief. Based on the foregoing, a new VA examination and medical opinion are needed. Regarding the lumbar spine claim, the Veteran underwent a VA examination in September 2015. He testified at the October 2020 hearing that the disability had increased in severity since that time. As such, an additional examination is appropriate. Finally, the record indicates that the Veteran may be unable to work in part due to his service-connected lumbar spine disability on appeal. See, e.g., October 2020 Bd. Hrg. Tr. and January 2021 representative written brief. Therefore, the AOJ should develop the issue of entitlement to TDIU in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). The case is REMANDED for the following actions: 1. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his claimed nasal/sinus, insomnia, hearing loss, and lumbar spine disorders and in support of his TDIU claim. This should specifically include treatment from Dr. Barrick dated from November 2018 to the present. See October 2020 Bd. Hrg. Tr. at 4. [NOTE: Numerous private records were received in October and November 2020, so the Veteran should authorize release only of any additional, non-duplicative records.] After acquiring this information and obtaining any necessary authorization, obtain and associate these records with the claims file. 2. Obtain any outstanding VA treatment records, including: (1) any audiological testing results in the Computerized Patient Record System (CPRS) Tools/Vista Imaging or other database, including the 2015 audiogram from the August 2015 VA audiology consultation (referenced in the February 2016 VA examination report) and (2) updated treatment dated from September 2017 to the present from the Castle Point VA Medical Center, including for acupuncture treatment for the lumbar spine disability. 3. DO NOT SCHEDULE THE FOLLOWING UNTIL THE ABOVE VA AND PRIVATE RECORDS ARE OBTAINED TO THE EXTENT POSSIBLE. 4. Refer the Veteran's claims file to a VA examiner for an opinion as to the nature and etiology of his allergic rhinitis. An examination of the Veteran should only be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. It is noted that the Veteran had qualifying service from January 1982 to April 1982 and from April 1987 to February 2011. The examiner should state whether it is at least as likely as not that the Veteran's allergic rhinitis manifested in or is otherwise related to any period of his qualifying service, including any symptomatology therein. The September 2015 VA examination report addressed sinusitis but did not address allergic rhinitis. The Veteran has contended that he has a nasal disorder that began during his period of qualifying service from 1987 to 2011. See March 2017 written appellate brief; October 2020 Bd. Hrg. Tr. (testified that started using flonase for allergies and sinuses beginning in early 2000 and that he still used that medication). The service treatment records (which include VA and private treatment records in addition to military facility records) show that the Veteran received treatment for sinus problems and seasonal allergies. See, e.g., service treatment records from August 1996, October 1997 (nasal congestion), April 1999, March 2003 (assessment including SAR [appears to be seasonal allergic rhinitis], plan including flonase); in-service VA treatment records from September 2004 (noted seasonal allergies) and November 2005 (reported post-nasal drip and sneezing, requested flonase refill for sinus); March 2007 private treatment record (various symptoms with assessment of sinusitis and plan including flonase). The post-service treatment records show reported allergies and a current diagnosis of allergic rhinitis. See, e.g., April 2015 VA treatment record; private treatment records from May 2016 and November 2017 (current diagnosis of allergic rhinitis). The referenced treatment records are contained in November 2015, January 2016, November 2016, and November 2020 claims file entries. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. Refer the Veteran's claims file to a VA examiner for an opinion as to the nature and etiology of his insomnia. An examination of the Veteran should only be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. It is noted that the Veteran had qualifying service from January 1982 to April 1982 and from April 1987 to February 2011. The examiner should state whether the in-service and post-service notations of insomnia during the course of treatment represent a symptom of the now service-connected mental health disorder (PTSD and major depressive disorder) and/or sleep apnea, as opposed to a separately diagnosable disorder. Only if the examiner determines that that the Veteran has a separately diagnosable insomnia disorder (rather than a symptom of the mental health and/or sleep apnea disabilities), he or she should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to any period of the Veteran's qualifying service, including any symptomatology therein. The Veteran has contended that his insomnia began during his period of qualifying service from 1987 to 2011. See October 2020 Bd. Hrg. Tr.; see also, e.g., October 2010 VA treatment record (during service) and January 2011 retirement examination report and report of medical history; VA treatment records from November 2016 and January 2017 (after service) (first record notes current target symptoms include insomnia, second record notes Veteran reported episodes usually when he has been feeling anxious). A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. Schedule the Veteran for a VA examination to determine the nature and etiology of any current right ear hearing loss that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment and personnel records, post-service medical records, and statements. It is noted that the Veteran had qualifying service from January 1982 to April 1982 and from April 1987 to February 2011. The examiner should state whether it is at least as likely as not that the Veteran has right ear hearing loss that manifested in or is otherwise related to any period of his qualifying service, including noise exposure and sinus-related symptomatology therein. See also February 2016 VA examination report (reported in-service duties). In providing this opinion, the examiner should consider the in-service audiological evaluations conducted from 1984 to 2011, as well as the contention from the Veteran's representative that his hearing loss could be related to potential ear damage from his in-service sinus problems. See March 2017 written appellate brief. The service treatment records (which include VA and private treatment records in addition to military facility records) show that the Veteran received treatment for sinus problems and seasonal allergies. See, e.g., service treatment records from August 1996, October 1997 (nasal congestion), April 1999, March 2003 (assessment including SAR [appears to be seasonal allergic rhinitis], plan including flonase); in-service VA treatment records from September 2004 (noted seasonal allergies) and November 2005 (reported post-nasal drip and sneezing, requested flonase refill for sinus); March 2007 private treatment record (various symptoms with assessment of sinusitis and plan including flonase). The referenced treatment records are contained in November 2015, January 2016, November 2016, and November 2020 claims file entries. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. Schedule the Veteran for a VA examination to ascertain the current severity and manifestations of his service-connected degenerative arthritis of the lumbar spine, including any neurological manifestations of the disability. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. 8. After completing the foregoing development, consider whether the Veteran is entitled to TDIU based on impairment attributable to his service-connected disorders, in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). See October 2020 Bd. Hrg. Tr. and January 2021 representative written brief and referenced treatment records/medical opinions. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Postek, 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.