Citation Nr: 21040098 Decision Date: 07/02/21 Archive Date: 07/02/21 DOCKET NO. 14-37 948 DATE: July 2, 2021 ORDER Entitlement to a disability rating of 70 percent, but no higher, for cirrhosis of the liver with portal hypertension is granted with an effective date of October 28, 2013 to January 20, 2021. Entitlement to an increased rating in excess of 40 percent for Hepatitis C is denied. Entitlement to an increased rating to 60 percent, but no higher, for chronic kidney disease from December 28, 2010, and to 80 percent from December 23, 2019, is granted. Entitlement to service connection for major depressive disorder (claimed as acquired psychiatric condition to include PTSD and depression) is denied. REMANDED Entitlement to service connection for gastrointestinal disorder claimed as hiatal hernia, acid reflux, or constipation is remanded. Entitlement to service connection for sleep apnea or sleeping disorder is remanded. FINDINGS OF FACT 1. Prior to January 21, 2021, the Veteran's cirrhosis manifested as history of two or more episodes of ascites, hepatic encephalopathy, but with periods of remission between attacks; but not as generalized weakness, substantial weight loss, and persistent jaundice, or with one of the following refractory to treatment: ascites, hepatic encephalopathy, hemorrhage from varices or portal gastropathy (erosive gastritis). 2. During the appeal period, the Veteran's hepatitis C disability manifested as varying levels of fatigue and malaise, with hepatomegaly; but not with substantial weight loss (or other indication of malnutrition), or in incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and upper right quadrant pain) having a total duration of at least six weeks, but not occurring constantly, during the past 12-month period. 3. The Veteran's CKD resulted in definite decrease in kidney function but did not result in persistent edema and albuminuria with blood urea nitrogen (BUN) 40-80 mg percent, creatinine 4-8 mg percent, generalized poor health, regular dialysis, or limitation to sedentary activities prior to December 23, 2019. 4. The Veteran's CKD resulted in lethargy, weakness, and limitation of exertion from December 23, 2019 but not in dialysis treatment, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or, BUN more than 80mg percent; or, creatinine more than 8mg; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. 5. The Veteran did not have a diagnosed psychiatric condition that was shown to be related to an event, injury, or disease during active service or resulting from a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for an increased rating to 70 percent, but no higher, for cirrhosis of the liver with portal hypertension have been met from October 28, 2013 and prior to January 21, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.114, DC 7312. 2. The criteria for an increased disability rating in excess of 40 percent for Hepatitis C have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.114, DC 7354. 3. The criteria for entitlement to an increased disability rating to 60 percent, but no higher, for chronic kidney disease have been met from December 28, 2010 and to 80 percent from December 23, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.3, 4.7, 4.115, DC 7541. 4. The criteria for entitlement to service connection for an acquired psychiatric disorder claimed as major depressive disorder have not been met. 38 U.S.C. § 1101, 1110, 1112, 1116, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1969 to December 1971. This matter comes before the Board on appeal from July 2014, September 2014, May 2016, and August 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in September 2020, where the issues on appeal were remanded for further evidentiary development. Increased Rating 1. Entitlement to a disability rating of 70 percent, but no higher, for cirrhosis of the liver with portal hypertension is granted with an effective date of October 28, 2013. 2. Entitlement to an increased rating in excess of 40 percent for Hepatitis C is denied. The Veteran contends that his liver conditions are worse than contemplated by the currently assigned ratings. The Board notes that this case has complex and overlapping hepatic symptoms under multiple Diagnostic Codes (DCs). The Board finds that a 70 percent disability evaluation for cirrhosis of the liver is warranted from the date of entitlement to service connection for Hepatitis C, October 28, 2013. The Board finds that an increased disability rating in excess of 40 percent for Hepatitis C alone is not warranted. The Board finds that the Veteran's carcinoma of the liver is in remission as of January 21, 2021 and will not disturb the prior 100 percent rating under DC 7343 for hepatocellular carcinoma in effect from February 13, 2019 to January 20, 2021. The Board finds that these disabilities of the liver are part and parcel of the Veteran's initial increased rating claim for Hepatitis C, the original claim of October 28, 2013, and is taking jurisdiction of these together. In its September 2020 decision, the Board referred the issue of a potential separate rating for the Veteran's cirrhosis of the liver under Diagnostic Code 7312. In a March 2021 rating decision, the AOJ assigned a separate rating of 100 percent for cirrhosis with portal hypertension with an effective date of January 21, 2021, the effective date ending the Veteran's 100 percent rating for hepatic carcinoma. Previously, the Board had granted a separate rating for portal hypertension, which is one of the symptoms used to evaluated cirrhosis under DC 7312, accordingly, that rating was absorbed into the new DC 7312. Disability ratings are intended to compensate for impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.27. It is necessary to rate the disability from the point of view of the Veteran working or seeking work, see 38 C.F.R. §§ 4.1, 4.2, and to resolve any reasonable doubt regarding the extent of the disability in the Veteran's favor. 38 C.F.R. § 4.3. Evaluations are based on functional impairments which impact a veteran's ability to pursue gainful employment. 38 C.F.R. § 4.10. If there is a question as to which disability rating to apply to the Veteran's disability, the higher rating 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. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; see Peyton v. Derwinski, 1 Vet. App. 282 (1991). In general, the degree of impairment resulting from a disability is a factual determination, and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Nonetheless, separate, or staged, ratings can be assigned for separate periods during the initial rating period on appeal based on the facts found. See O'Connell v. Nicholson, 21 Vet. App. 89, 91-92 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114, Schedule of ratings-digestive system. Regarding diseases of the digestive system, the ratings schedule acknowledges, "certain co-existing diseases in this area, as indicated... do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding as outlined in § 4.14." 38 C.F.R. § 4.113. The Veteran's symptoms for cirrhosis of the liver are rated under DC 7312 at 100 percent from January 21, 2021, accordingly this analysis will focus on the period prior to that date. Under DC 7312, cirrhosis with symptoms such as weakness, anorexia, abdominal pain, and malaise are rated at 10 percent; portal hypertension and splenomegaly, with weakness, anorexia, abdominal pain, malaise, and at least minor weight loss is rated at 30 percent; cirrhosis with history of one episode of ascites, hepatic encephalopathy, or hemorrhage from varices or portal gastropathy (erosive gastritis) is rated 50 percent disabling; cirrhosis with history of two or more episodes of ascites, hepatic encephalopathy, or hemorrhage from varices or portal gastropathy (erosive gastritis), but with periods of remission between attacks, is rated 70 percent disabling; cirrhosis with generalized weakness, substantial weight loss, and persistent jaundice, or with one of the following refractory to treatment: ascites, hepatic encephalopathy, hemorrhage from varices or portal gastropathy (erosive gastritis), is rated 100 percent disabling. Note 1 to DC 7312 provides that, for rating under DC 7312, documentation of cirrhosis (by biopsy or imaging) and abnormal liver function tests must be present. 38 C.F.R. § 4.114. The Veteran is assigned a 40 percent disability rating under Diagnostic Code 7354 for hepatitis C infection. DC 7354 provides for a 10 percent rating for hepatitis C manifested by intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12- month period; 20 percent rating is warranted for hepatitis C manifested by daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period; 40 percent rating is warranted for hepatitis C manifested by daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and upper right quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period; 60 percent rating is warranted for hepatitis C manifested by daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and upper right quadrant pain) having a total duration of at least six weeks, but not occurring constantly, during the past 12-month period; 100 percent rating is warranted for hepatitis C manifested by near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). Id. Note (1) to Diagnostic Code 7354 provides for evaluation of sequelae, such as cirrhosis or malignancy of the liver, under an appropriate diagnostic code, but prohibits use the same signs and symptoms as the basis for evaluation under Diagnostic Code 7354 and under a diagnostic code for sequelae. Note (2) provides that "incapacitating episode" means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. For purposes of evaluating conditions in 38 C.F.R. § 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. 38 C.F.R. § 4.112. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. Id. Private medical treatment record dated October 16, 2013 notes diagnoses of portal hypertension and cirrhosis without alcohol involvement as well as esophageal varices without bleeding. In July 2013, the doctor recorded "obvious ascites" and noted in September 2013, "current ascites." While an August 2013 record did not note ascites. A September 2014 medical record also notes cirrhosis of the liver and portal hypertension. An October 2014 letter from Dr. G. describes the Veteran as having advanced liver disease and portal hypertension that causes endurance and stamina limits. At the June 2014 VA examination, the Veteran weighed 181 pounds. The examiner noted diagnosis of hepatitis C. The Veteran reported that his liver values were normal, denied jaundice, and noted that his abdomen was enlarging. The Veteran reported being on a medication for fluid retention. The Veteran reported chronic fatigue, occasional nausea, and rare vomiting. The examiner listed symptoms related to infectious disease as daily fatigue and noted hepatomegaly. The examiner noted that the Veteran had swelling in the legs and stomach. There were no reported incapacitating episodes. The examiner did not note any symptoms related to cirrhosis and did not note a cirrhosis diagnosis. The Veteran's weight was noted to be stable, as it had been 185 pounds in 2009. The examiner noted a large protuberant abdomen with tenderness to palpation in the right upper quadrant. The Veteran's creatinine was 0.9. The Veteran noted that due to increased fatigue, he would not be able to do things like cut the lawn or excessive standing or walking. At the April 2016 VA examination for liver disorders, the examiner confirmed diagnosis of hepatitis C from 2007 and for cirrhosis from February 2013 by biopsy. The Veteran reported a 20-pound weight gain while undergoing a recent treatment. The Veteran reported he stopped mowing the lawn 15 years prior due to fatigue and shoulder problems from previous work as bus driver. The Veteran was able to ambulate from the parking lot and through building with some pause to catch his breath. The examiner did not list symptoms under the infectious disease section and reported no incapacitating episodes. Under cirrhosis, the examiner marked symptoms of intermittent weakness, and portal hypertension. The examiner noted the Veteran was mildly obese and weight 209 pounds. The Veteran's abdomen was firm and mildly distended. The examiner noted a 2009 scan showing liver consistent with early cirrhosis or hepatitis. At the April 2019 VA examination for liver disorders, the examiner noted diagnoses of cirrhosis of the liver, hepatitis C, and carcinoma of the liver diagnosed at the examination. The examiner noted that a CT scan from October 2016 showed hepatitis C cirrhosis. The examiner noted symptoms of near-constant debilitating fatigue, daily malaise, and intermittent right upper quadrant pain, and no incapacitating episodes, listed under infections disease. Under symptoms for cirrhosis of the liver, the examiner checked daily malaise, and intermittent abdominal pain. The examiner noted that the Veteran did not have the requisite strength to do work, including sedentary work. May 2019 private treatment records note constant right upper quadrant pain with fatigue and loss of appetite. There was no lower extremity swelling. The Veteran denied nausea or vomiting. An October 2019 CAPRI note reported no unexplained weight loss. At the December 2019 VA examination for liver disorders, the examiner noted diagnoses of cirrhosis of the liver, hepatitis C, and carcinoma of the liver. The Veteran reported a history of hepatic encephalopathy for which he took a preventative medication. The Veteran also reported treatment every 3 weeks for ascites. The examiner marked no symptoms attributable to infectious disease and no incapacitating episodes. The examiner marked symptoms relating to cirrhosis as daily weakness, intermittent abdominal pain, daily malaise, ascites with 2 or more episodes with periods of remission between attacks, and hepatic encephalopathy with 2 or more episodes with periods of remission between attacks. The examiner stated that the Veteran's liver condition causes general malaise which would make any strenuous task difficult. The Veteran also had recurrent ascites which made him short of breath. In January and March 2021, the VA examiner's opinion explained that for these liver disorders, it is difficult or not possible to distinguish which symptoms are from which disability. Based on the overall record prior to January 21, 2021, the Board finds that a 70 percent disability rating is warranted for the Veteran's cirrhosis of the liver. The Veteran experienced regular episodes of ascites and eventually of hepatic encephalopathy that were treated and had periods of remission between episodes and were not reported to be refractory to treatment. While the Veteran did have generalized weakness, he did not have substantial weight loss or reported jaundice which pertain to the 100 percent disability rating. The medical record of evidence documents a biopsy in 2013 showing cirrhosis. Accordingly, the Board finds that the entitlement to a separate rating for cirrhosis under DC 7312 is most appropriate from October 28, 2013, the date of claim for hepatitis, and at a 70 percent disability rating. As for the Veteran's hepatitis C infection, the Board finds that an increased rating in excess of 40 percent is not warranted. While the Veteran exhibited symptoms of fatigue, malaise, nausea and right upper quadrant pain throughout the appeal period, either consistently or intermittently, the fatigue was reported as near-debilitating in April 2019, while other symptoms, including fatigue, were reported as daily or intermittent throughout the period on appeal. The Veteran had hepatomegaly. The Veteran was not reported as anorexic. The Veteran did not have reported incapacitating episodes due to hepatitis C. As there are symptoms from various disability levels within the DC 7354 criteria, the Board finds that the Veteran's symptoms for hepatitis C most approximate the 40 percent level. 3. Entitlement to an increased rating to 60 percent, but no higher, for chronic kidney disease from December 28, 2010, and to 80 percent from December 23, 2019, is granted. The Veteran contends that his chronic kidney disease (CKD) with hypertension disability is worse than contemplated by the currently assigned 30 percent rating. After a thorough review of the evidence, the Board finds that a 60 percent disability rating from December 28, 2010, and an 80 percent disability rating from December 23, 2019 is warranted. The Veteran's CKD is evaluated under Diagnostic Code 7541 at 30 percent from December 28, 2010. 38 C.F.R. §§ 4.115a, 4.115b. Under that code, a 30 percent rating is warranted for albumin constant or recurring with hyaline and granular casts or red blood cells, or transient or slight edema or hypertension at least 10 percent disabling under DC 7101; a 60 percent rating is warranted for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under Diagnostic Code 7101. 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7541. Diagnostic Code 7101 provides that hypertension is 40 percent disabling when diastolic pressure is 120 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. An 80 percent rating is warranted for persistent edema and albuminuria with BUN 40 to 80mg percent; or, creatinine 4 to 8mg percent; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. 38 C.F.R. §§ 4.115a, 4.115b, Diagnostic Code 7541. A 100 percent rating is warranted where regular dialysis is required, or more than sedentary activity is precluded from one of the following: persistent edema and albuminuria; or, BUN more than 80mg percent; or, creatinine more than 8mg; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. Id. The VA examination for diabetes and associated lab report shows creatinine level at 0.88. In June 2011, the private treatment records show diagnosis of CKD stage I with BUN at 8 and no edema. In December 2011, records show CKD stage I with no edema reported. In June 2012, records reflect that the doctor explained to the Veteran that his kidneys were continuing to decline due to diabetes and drinking alcohol. Private treatment records from September 2014 show diagnosis of CKD in stage I. August 2013 showed no edema. September 2013 labs showed BUN level 15 and creatinine at 0.98. May 2014 lab results show BUN level of 11 and creatinine at 0.81. January 2015 records describe the CKD as asymptomatic but noted edema in the extremities. May 2017 CAPRI record showed BUN level of 16 and creatinine level of 0.90. May 2018 CAPRI record shows BUN level of 21 and blood pressure of 172/86. The examiner noted the Veteran was "pale-looking." A May 2018 private treatment record shows blood pressure of 161/100 and no edema and proteinuria. Creatinine level from April 2018 was 1.29. May 2019 private treatment records show the Veteran denied lower extremity swelling. October 2019 CAPRI record notes minimal edema and blood pressure reported as 138/66. November 2019 CAPRI record notes edema in the knees. The December 23, 2019 VA examination for renal disorders reflects a diagnosis of CKD. The examiner noted symptoms of persistent proteinuria/albuminuria, transient edema, lethargy, weakness, limitation of exertion and decreased ability to perform strenuous tasks. The AOJ obtained an addendum VA opinion in November 2020 wherein the examiner reviewed the Veteran's history of CKD and determined that the Veteran has not been on dialysis, there was history of persistent albuminuria, but not markedly decreased kidney function, no substantial weight loss, but there had been a gradual decline in kidney function from 2008-2019. Based on the intermittent appearance of edema, the sporadic but increasingly consistent albuminuria, and the VA examiner's review that over the appeal period, the Veteran had a decline in renal function but not markedly so, the Board finds that the Veteran's CKD with hypertension symptoms most nearly approximate a 60 percent disability prior to December 23, 2019. The Veteran has not been on dialysis and was not precluded from more than sedentary activity for the factors listed in the 100 percent rating category. From December 23, 2019, the VA examiner noted that the Veteran had lethargy, weakness, and limitation of exertion due to renal dysfunction which more closely approximates the 80 percent disability evaluation for renal dysfunction under DC 7541 for the Veteran's CKD with hypertension. When evaluating a claim for an increased schedular disability rating, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204 (1994). While the Veteran is competent to report that his symptoms are worse, the training and experience of medical personnel makes the medical findings found in treatment notes and examinations more probative as to the extent of the disability. See Cromley v. Brown, 7 Vet. App. 376 (1995). Accordingly, the Board finds that an award of an increased disability rating for CKD with hypertension to 60 percent, but no higher, from December 28, 2010, and to 80 percent from December 23, 2019 is warranted, and to that extent this appeal is granted. Service Connection 4. Entitlement to service connection for major depressive disorder (claimed as acquired psychiatric condition to include PTSD and depression) is denied The Veteran contends that he has a psychiatric disorder as a result of active service or from a service-connected disability. After a thorough review of the evidence, the Board finds that entitlement to service connection for an acquired psychiatric condition is not warranted. As a lay person, the Veteran is competent to testify as to facts which he experienced firsthand. Layno v. Brown, 6 Vet. App. 465, 471 (1994); Harvey v. Brown, 6 Vet. App. 390, 394 (1994). Once the threshold of competency is met, the Board must then consider the credibility of the assertions. In the Veteran's service treatment records, the separation medical examination in 1971 does not note any psychiatric issues. The remaining service medical records do not document complaints of or treatment for psychiatric issues. In a June 2004 VA psychiatric record, the Veteran complained of increasing isolation and depressed mood for the past few years, referencing the death of his mother and brother as stressors. The examiner diagnosed depression and noted a related prescription medication. At the May 2014 VA PTSD examination, the examiner diagnosed major depressive disorder and determined that the Veteran did not meet the criteria for diagnosed PTSD. The examiner considered statements and history from the Veteran including that he had mental health treatment from a doctor in 1974-1975 era and received prescription medication and was diagnosed with depression in 2004. The examiner provided an addendum opinion that after the examination and reviewing the Veteran's medical history and records that the Veteran's depressive disorder was not related to active service or to the claimed stressors. The Veteran argued in the October 2014 notice of disagreement that this examination was inadequate. The Board finds that this examination was adequate and where the opinion did not discuss secondary service connection, the Board subsequently requested another opinion. The VA examination is adequate, as it is predicated on consideration of the medical records in the Veteran's claims file, to include the Veteran's statements, and documents that the examiner conducted a full psychiatric examination of the Veteran. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). A September 2012 and February 2016 CAPRI record shows a depression screen was negative. An April 2017 private treatment record and May 2017 CAPRI record notes that the Veteran denied problems with depression. May 2017 and May 2018 depression screens in CAPRI were negative. In the December 2020 addendum VA medical opinion, the examiner reviewed the Veteran's records and determined that the Veteran did not have a current psychiatric condition in agreement with the April 2019 VA examiner's determination that there was not a diagnosed mental health disorder per DSM IV or V criteria. The examiner noted that there was a previous diagnosis of depressive disorder earlier in the appeal period as well as treatment for mental health issues in the 1980s, but that the evidence did not support that the related symptoms at that time were continuous or the same entity from active service nor are they related to the service-connected diabetes or hepatitis C. In this regard, the Board recognizes the Veteran's statements that he feels he has a psychiatric condition that is related to active service or to his service-connected disabilities. The evidence of record does not support a nexus between any diagnosed psychiatric condition and service or the Veteran's currently service-connected disabilities. While the Veteran may believe it is a natural consequence, medical opinions are more probative as the Veteran does not have the requisite medical expertise to determine a diagnosis or that nexus. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for a psychiatric disability. The benefit of the doubt doctrine is not for application, and entitlement to service connection for an acquired psychiatric disability, to include PTSD, is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for gastrointestinal disorder claimed as hiatal hernia, acid reflux, or constipation is remanded. 2. Entitlement to service connection for sleep apnea/sleeping disorder is remanded. On the Veteran's original claim form dated October 28, 2013, he claimed entitlement to service connection for gastrointestinal disorder and sleep disorder, for each, he wrote as direct and secondary. In its September 2020 rating decision, the Board noted that the Veteran had undergone a sleep study in 2019 and requested the associated records be obtained by the RO. CAPRI records show the Veteran was subsequently assigned a CPAP machine in January 2020. One of the reasons that the RO denied the entitlement to service connection in the initial July 2014 rating decision was a lack of diagnosed sleep condition. These additional records have not been associated with the claims file. The Veteran has not been afforded a VA sleep disorders examination. As for the gastrointestinal disorder claim, because the Veteran has multiple liver conditions that may result in gastrointestinal issues or mimic such issues, and is taking multiple prescription medications, which is one of the secondary theories he espoused in the 2013 claim, the Veteran should be afforded a VA examination for gastrointestinal disorders. The matters are REMANDED for the following action: 1. With the Veteran's assistance if necessary, obtain the related medical records for the 2019 sleep study. 2. Schedule the Veteran for a VA examination for his sleep disorder claim. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: (a.) Direct service connection Is any diagnosed sleep disorder at least as likely as not related to service? Provide a rationale to support the opinion(s). Please note the sleep study from 2019 and subsequent CPAP machine in January 2020. (b.) Secondary service connection Is any diagnosed sleep disorder at least as likely as not proximately due to any service-connected disabilities? (c.) Is any diagnosed sleep disorder at least as likely as not aggravated, i.e., worsened beyond its natural progression, by a service-connected disability? 3. Schedule the Veteran for a VA examination for his gastrointestinal disorder claim. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: (a.) Direct service connection Is any diagnosed gastrointestinal disorder at least as likely as not related to service? Provide a rationale to support the opinion(s). (b.) Secondary service connection Is any diagnosed gastrointestinal disorder at least as likely as not proximately due to any service-connected disabilities, to include medication and/or treatment for those disabilities? (c.) Is any diagnosed gastrointestinal disorder at least as likely as not aggravated, i.e., worsened beyond its natural progression, by a service-connected disability? 4. The examiner should cite to the pertinent medical and competent lay evidence of record and explain the rationale for all opinions given. If after consideration of all pertinent factors it remains that the opinion sought cannot be given without resort to speculation, it should be so stated, and the provider must (to comply with governing legal guidelines) explain why the opinion sought cannot be offered without resort to speculation. 5. Thereafter, readjudicate the claims on appeal. Idongesit T. Umo Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Miller, 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.