Citation Nr: 21041054 Decision Date: 07/08/21 Archive Date: 07/07/21 DOCKET NO. 18-02 899 DATE: July 8, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is granted. Entitlement to service connection for traumatic brain injury (TBI) (also claimed as head injury) is denied. REMANDED Entitlement to service connection for status post right eye vitrectomy, membrane peal and focal laser with residual macular scars (also claimed as decreased visual acuity, retinal detachment and scar) as secondary to TBI is remanded. Entitlement to service connection for rhinitis (claimed as sinusitis) is remanded. Entitlement to service connection for benign paroxysmal positional vertigo (BPPV) is remanded. Entitlement to an earlier effective date of September 6, 2012 for sciatica, right lower extremity is remanded. Entitlement to a higher initial rating for sciatica, right lower extremity is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his OSA is at least as likely as not related to service. 2. The preponderance of the evidence of record is against finding that the Veteran has had a diagnosis of TBI or residuals of TBI related to in-service events. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for OSA are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for TBI (also claimed as head injury) are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2004 to October 2004 and from May 2006 to August 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for OSA is granted. The Veteran asserts that he developed symptoms of sleep apnea while on active duty. The Board concludes that the Veteran has a current diagnosis of OSA that is related to service. During his April 2021 Board hearing, the Veteran testified that although he did not fully know how his symptoms presented, he experienced problems with sleeping. He also testified that he was unaware he stopped breathing while sleep, until his partner told him. He subsequently began seeking treatment for his sleep problems. Service treatment record include a July 2007 post-deployment health assessment shortly before the Veteran's return from Kuwait. The assessment indicates that the Veteran reported still feeling tired after sleeping. In a January 2008 post deployment health reassessment, the Veteran again reported problems sleeping or still feeling tired after sleeping. Thus, the question becomes whether the Veteran's current sleep apnea is related to service. On this question there are probative opinions in favor of and against the claim. The file includes a May 2015 VA examination report, which indicates that the Veteran has mild obstructive sleep apnea (OSA); a nexus opinion was not provided The evidence against the claim includes a February 2018 VA opinion wherein a VA examiner opined that the Veteran's OSA was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner's rationale indicated that "the earliest record noting trouble sleeping was with a post deployment exam" in January 2008. The examiner explained that the Veteran received treatment for mental health and had gained weight. The examiner further explained that most sleep disorders in the VA system were evaluated by mental health and the Veteran's insomnia was diagnosed and treated with some success. The examiner noted that the Veteran's diagnosis of OSA was made several years and 30 pounds later and it was well accepted that the most common cause for OSA was obesity. Thus, it appeared that the Veteran's obesity was more likely as not the cause of the Veteran's sleep apnea. The evidence in favor of the claim includes a June 2016 nexus opinion provided by a private physician, Dr. R.C.S, a specialist in pulmonary, critical care, and sleep medicine. Dr. R.C.S. indicated that he reviewed the Veteran's records, based on the Veteran's report, his OSA developed while on active duty, although not as a result of military service. Upon reviewing the record and the medical opinions, the Board assigns more probative weight to Dr. R.C.S.' opinion as he appears to have considered the Veteran's lay report of onset and symptoms and is a pulmonary specialist. The February 2018 VA opinion is somewhat less probative because it is partially based on inaccurate facts. As indicated above, service treatment records show the Veteran first reported sleep trouble in July 2007, and not in January 2008, after returning from his deployment. Resolving all reasonable doubt in favor of the Veteran, service connection for obstructive sleep apnea is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for TBI (also claimed as head injury) is denied. The Veteran contends that he has TBI resulting from multiple in-service head injuries. Service records show the Veteran was deployed to Southwest Asia (SWA) from July 2006 to July 2007. His DD 214 does not reflect any awards indicative of combat, but he is noted to have served in Iraq from July 12, 2006 to July 15, 2007, in a designated imminent danger pay area. Service treatment records show include a June 2003 medical examination for enlistment; no relevant diagnoses were made. On the Report of Medical history, the Veteran denied headaches or history of head injury. The Veteran's May 2006 SWA pre-deployment examination report is of record. No complaints were noted, and the Veteran was not referred for any pre-deployment health provider follow-up. A July 3, 2007 post- deployment assessment report shows the Veteran reported headaches during his deployment. He denied being engaged in direct combat. A July 17, 2007 Report of Medical Assessment shows the Veteran reported that he suffered a head injury during active duty for which he did not seek medical care. In a January 2008 post deployment health reassessment, the Veteran reported various symptoms including, but not limited to, headaches and difficulty remembering. He also noted exposure to 'blasts or motor vehicle accident' while deployed that caused a jolt or blow to his head. A March 2008 Report of Medical Examination shows a neurological system evaluation was normal; PTSD was noted as a concern, however. On the accompanying Report of Medical History, the Veteran reported a head injury and memory loss. He noted that he was involved in an auto wreck in January 2006 and sustained a laceration to the back of his scalp that was sutured; he could not recall the details due to his head injury. He also reported that in the spring of 2007, while in Baghdad, he walked into an air condition that was hanging out of a window. He hit the front of his head near the hairline, fell to the ground, and stayed until he regained his composure. The Veteran also reported that he began to experience lapse in memory in the spring of 2007. Exposures to blast events were not reported. Reserve records include a March 2008 VA neuropsychological assessment of a positive TBI screen. The Veteran indicated that he was involved in a motor vehicle accident (MVA) in January 2006, months prior to his active duty service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. After careful review of the competent evidence, the Board concludes that the Veteran does not have a current diagnosis of a TBI or post-concussive syndrome related to claimed service events and has not had one at any time during the pendency of the claim or recent to the filing of the claim. At the hearing before the undersigned, the Veteran reported that he walked into an air conditioner that was hanging out of the window of a building and was knocked down to the ground. He noted immediate swelling in my head, dizziness, and then began experiencing headaches, vertigo, and slurred speech. He also testified that he was exposed to incoming indirect fire attack, either mortar or rocket. During one alleged incident, another solder pulled him between two trailers to avoid incoming fire and he hit his head on one of the trailers. He recalled that he did not lose consciousness, but saw stars. The Veteran reported a third incident during which a suicide bomber is alleged to have detonated an explosive vest within his company area. He recalled the blast "shook everything." He expressed his belief that his symptoms of memory deficiency, attention problems, speech, concentration difficulties were related to these events. While the Veteran believes he has a current diagnosis of TBI or suffers from residuals of a TBI, he is not competent to provide such a diagnosis. The issue is medically complex, as it requires specialized medical education. To that extent, the Board acknowledges the buddy statement provided by J.M., who reportedly witnessed his head injury with the air conditioner unit. However, she is also not competent to provide a diagnosis of TBI. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board must evaluate the medical evidence found in VA and private medical records and opinions, and the April 2015 VA examination report. The evidentiary record contains conflicting findings as to whether the Veteran has current diagnosis of TBI, post-concussive syndrome, or other chronic disorder manifested as residuals of any head injuries in service. VA treatment records include a positive TBI screen in February 2008. Further neuropsychological and polytrauma evaluations were conducted in March 2008 and the Veteran's reported history of blast exposures, a low-velocity forehead contusion (i.e. walking into an air conditioner while reading his mail), and other clinical history was considered. The clinicians also considered the Veteran's reported head injury in January 2006, not during a period of active duty, where he reportedly was involved in a minor car crash and hit his head on part of the car frame. The Veteran was noted to have difficulty recalling certain aspects of his deployment in Iraq. Following one of these neuropsychological evaluations, one of the examining clinicians (a physiatrist) determined there were no findings consistent with a diagnosis of TBI or a post-concussion syndrome. Rather, the symptoms were more consistent with psychological issues such as anxiety or possibly PTSD. Following another comprehensive neuropsychological evaluation, another clinician (a neuropsychologist) similarly determined that the Veteran's reported difficulties, including his reported difficulties with cognitive functioning, were not related to a TBI or the very mild concussions he had experiences. A diagnosis of adjustment disorder with anxious features was rendered. The Veteran was afforded a VA examination in April 2015. The examination was performed by a neurologist and neuropsychologist- the latter, being the same doctor who evaluated the Veteran at his March 2008 neuropsychological evaluation. The VA examination report contains a detailed account of the Veteran's self-report of head injuries and blast exposure events while deployed to Iraq, and such history was considered by the examiners. The examiners noted that although the Veteran described numerous incidents in which there were blasts during his deployment to Iraq, "none were associated with injury or with loss of consciousness (LOC), post traumatic amnesia (PTS), or alteration of consciousness (AOC)." The examination report referenced the Veteran's incident, where he hit his head on an air conditioner while walking and fell to the ground. It was noted that though the Veteran described being "confused" for a few moments, his description of confusion did not suggest an actual alteration in consciousness. The report also discussed the Veteran's involvement in a January 2006 motor vehicle accident (MVA) that resulted in a scalp laceration. The report noted that the Veteran did not lose consciousness, there was no PTA or clear evidence of AOC, and he was not diagnosed with a concussion. The examiners acknowledged, in the examination report, that the Veteran described a number of troubling symptoms during his VA polytrauma appointment in March 2008, but none had a clear nexus or temporal relationship to any of the events described by the Veteran as having possibly resulted in injury. The report pointed out that the VA doctor who examined the Veteran concluded that the findings were not consistent with a diagnosis of TBI or post-concussion syndrome and that psychiatric symptoms were suspected/probable. Additionally, one of the current VA examiners, the neuropsychologist, who treated the Veteran on the same date as his VA polytrauma evaluation in March 2008 and in a follow-up neuropsychological test performed April 2008 found that no significant deficits were identified on testing; rather, the Veteran's current subjective cognitive difficulties were relates to behavioral health factors. The examiners determined that a nexus or temporal relationship between head trauma and subjective memory problems, headaches or dizziness was not suggested in the Veteran's March 2008 PDHA. A 2014 polytrauma evaluation found that the Veteran's symptom presentation was most consistent with behavioral health conditions. The Veteran was again seen by the same VA neuropsychologist in June 2014 and it was revealed that he was diagnosed with sleep apnea, but not undergoing treatment, and developed an alcohol abuse problem, which he minimized in prior contacts. Although the Veteran reported that he minimized his injuries from 2006 to 2007 and believed them to be more severe than first described, it was noted that scientific research shows that memories for events tend to change over time, and are usually less accurate as increased time passed; thus, his memory for events was probably more accurate closer in time to the incidents. The 2014 polytrauma evaluation determined that even if the Veteran experienced a mild concussion between 2006 and 2007, it would not account for the change in performance between 2008 and 2014. The examination reported noted that the Veteran was not diagnosed with mild neurocognitive disorder or any other residuals of TBI. The report considered the Veteran's service-connected PTSD and migraine disabilities along with his pre-military history, noting that he had "long standing problems in reading and/or reading comprehension." The examination report summarized the examiners findings by explaining that the Veteran had undergone comprehensive second level TBI evaluations twice, in 2008 and 2014, and both concluded that he had no history of TBI or residuals of TBI. The Veteran was provided neuropsychological testing twice, in 2008 and 2014, and was not diagnosed with a neurocognitive disorder (DSM-5) or cognitive disorder, NOS (DSM-IV). The examiners determined that the Veteran did not suffer from a TBI or residuals of a TBI. The neurological examination was without evidence of abnormality related to TBI. In addition to the two neuropsychological testing performed earlier, on the date of examination, the Veteran completed the Neurobehavioral Symptom Checklist. The VA examiner noted that the Veteran endorsed moderate to very severe difficulties on all but 2 of the 22 items, obtaining a score of 58 which was more than double the score of 27 obtained on this same measure during his first polytrauma evaluation in March 2008. Such an escalation in symptom reporting over time was not consistent with the natural course of recovery following mild concussion, which was typically characterized by gradual improvement over time and then stabilization of symptoms (typically with full recovery). Thus, the Veteran's pattern of endorsement was not consistent with post-concussion disorder. The examination report concluded that there was no diagnosis of TBI, mild neurocognitive disorder, or any other DSM-5 diagnosis due to TBI. In January 2016 a staff psychologist for a private university traumatic brain injury program (Dr. D.G. L., II) wrote a referral letter for neuropsychological testing on behalf of the Veteran. Dr. D.G.L., II indicated that while the Veteran appeared to present with symptoms consistent with a mild neurocognitive disorder related to a TBI sustained during his military deployment, neuropsychological testing was not within his scope of practice. Dr. D.G.L., II acknowledged that a review of previous neuropsychological testing conducted by VA did not reveal anything remarkable and it was concluded that neurocognitive impairment was not apparent. Thus, the Veteran was encouraged to consider undergoing a neuropsychological evaluation to determine whether his self-reported difficulties could be attributed to a neurocognitive disorder due to TBI. The Veteran then sought treatment from a private clinical neuropsychologist, Dr. J.C. who noted the referral from the TBI program. In November 2016 Dr. J.C. provided a neuropsychological evaluation of the Veteran. In his report, Dr. J.C. explained the Veteran's medical history and current presenting problems. Dr. J.C. reported that the Veteran was involved in combat experience (though the Veteran previously reported in the July 2007 PDHA that he was not engaged in direct combat where he discharged his weapon) and recalled several head injuries to include 'hitting his head on a trailer' and not wearing a helmet at the time; however, the Veteran denied LOC. Dr. J.C. noted that the most significant injury was when the Veteran struck his head on an air conditioner unit and fell to the ground "with brief loss of consciousness." Dr. J.C. also noted the Veteran's symptoms of dizziness, vertigo, headaches, migraines, and difficulty with decreased attention, vocabulary knowledge and ability to maintain his train of thought. A mental status exam (MSE) was performed and revealed a mildly depressed mood, slow response, and no indication of embellishment of symptoms. General MSE was "low average with a score of 28/30 on the MMSE." The Veteran could recall 1/3 words spontaneously after short delay; otherwise, his performance was unremarkable on the MMSE. The results of the neuropsychological evaluation revealed that the Veteran experienced deficits in the domain of executive functioning, language, and cognitive efficiency. Dr. J.C. opined that these deficits were consistent with what can be seen in mild traumatic brain injury and are likely exacerbated by ongoing PTSD symptoms. In July 2020 the Veteran underwent a private speech-language pathology evaluation. The speech pathologist indicated the Veteran had experienced multiple head injuries between 2006 and 2007, with no immediate treatment at the time. She indicated that based on his description of where the brain trauma occurred, the frontal lobe and possibly the parietal lobe were the site of injury. The Veteran resubmitted Dr. J.C.'s November 2016 neuropsychological evaluation in October 2020; it was marked as an addendum report. In this addendum, Dr. J.C. essentially restated his prior findings from November 2016 and of relevance, included the DSM-5 diagnoses of major neurocognitive disorder secondary to mild traumatic brain injury, and PTSD, chronic. Upon review of the evidence of record, the Board finds the Veteran does not have a current diagnosis of TBI that is related to service events. At the outset, the Board observes that the service treatment records do not reflect treatment for a head injury following a reported collision with an air conditioning unit. The buddy statement from the person who reportedly witnessed such event is acknowledged. There is also no evidence of treatment for any head injury following incoming fire events. Nonetheless, VA examiners and private clinicians have offered medical opinions regarding whether the Veteran currently has a TBI or post-concussive syndrome disability related to the events he has reported. The VA examiners, who are neuropsychologist and physiatrist, are competent to evaluate and diagnosis TBI and post-concussive syndrome. Both examiners reviewed the Veteran's entire claims file and conducted comprehensive evaluations have determined that the Veteran does not suffer from TBI and post-concussive syndrome due to any of the reported events in service. The VA opinions are considered highly probative because they were based on an accurate medical history and provide detailed explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board also notes that the neuropsychologist who assisted with the VA examination in April 2015, was also familiar with the Veteran's history - having evaluated him multiple times, beginning in 2008 and again in 2014. The diagnosis and nexus opinion from Dr. J.C., who has diagnosed a current TBI, is afforded less probative weight than the VA opinions. In Dr. J.C's report, he stated that after the Veteran struck his head on the air conditioner unit and fell to the ground, he had "brief loss of consciousness." Yet, eight years earlier, and much closer in time to the incident, the Veteran reported that he "was confused for a few moments." The Veteran testified that he did not lose consciousness when he struck his head. Dr. J.C. did not explain this discrepancy and appears to have relied, in part, on an inaccurate factual premise. Further, the VA examiners' medical opinion is more comprehensive than that of Dr. J.C. The VA examiners accounted for the Veteran's neuropsychological testing performed in December 2007 to rule out the presence of a learning disability such as dyslexia. That December 2007 treatment note indicated that the Veteran had "long standing problems in reading and/or reading comprehension" (i.e. prior to military service)." Additionally, the process to rule out TBI began, which after a series of evaluations and testing, a diagnosis was not made. Rather, the Veteran's symptoms were related to behavioral conditions. Dr. J.C. did not address these findings or provide a clear explanation to rebut the multiple VA findings that reported that there was no TBI or residuals of a TBI present. Of significance, Dr. J.C. did not address the April 2015 VA examiners' report noting that "such an escalation in symptom reporting over time was not consistent with the natural course of recovery following mild concussion, which was typically characterized by gradual improvement over time and then stabilization of symptoms (typically with full recovery). Thus, the Veteran's pattern of endorsement was not consistent with post-concussion disorder." For these reasons, the Board assigns more probative weight to the April 2015 VA examination report. The Board has considered the speech-pathology report which refers to a brain injury, but it does not provide a sufficient basis to grant service connection. Any probative weight to be assigned to this diagnosis and opinion is outweighed by the more comprehensive 2015 VA medical opinion which was based on comprehensive neuropsychological testing and with a review of the Veteran's service and post-service clinical history. Finally, the October 2020 VA PTSD examination report indicates that he had a diagnosis of TBI based on the Veteran's self-report of such from a March 2016 VA neurology consult. However, there is no independent diagnosis of TBI offered, rather the Veteran's lay report of a TBI. Additionally, this finding is not accurate because as noted earlier, after undergoing multiple testing with VA, there were no findings of TBI or residuals of TBI. As the most probative and competent medical evidence fails to establish a present TBI or post-concussive disorder is related to head injuries and incoming fire/blast events that are reported to have occurred in service, the elements of service connection are not established. The preponderance of the evidence is against the claim and the benefit of the doubt rule is not applicable. Service connection for TBI is not warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND 1. Entitlement to service connection for status post right eye vitrectomy, membrane peal and focal laser with residual macular scars (also claimed as decreased visual acuity, retinal detachment and scar) as secondary to TBI is denied. The Veteran contends he has a detached right retina due to a TBI. Specifically, the Veteran asserts that after hitting his head on an air conditioner unit, which resulted in a TBI, he eventually underwent a vitrectomy to treat the detached retina. The Veteran was diagnosed with optic nerve pit with macular hole and central retinal detachment right eye in 2010; however, service connection for a TBI has been denied in the instant decision. As a matter of law, service connection for the right eye disability cannot be granted on a secondary basis as the Veteran is not service-connected for TBI. See 38 C.F.R. § 3.310. However, a May 2015 VA examiner opined that the optic nerve pit and leakage and macular detachment in 2010 (maculopathy) was less likely than not due to or the result of the injury suffered in 2007- rather the optic pit with subsequent leakage and retinal separation is a congenital 'condition.' VA distinguishes between congenital or developmental "defects" and "diseases" for service connection purposes. Distinguishing between a congenital disease and a congenital defect turns on whether the condition is dynamic or static in nature. A congenital disease is dynamic and "capable of improving or deteriorating." Quirin v. Shinseki, 22 Vet. App. 390, 394-95 (2009). On the other hand, a defect is a structural or inherent abnormality or condition that is more or less stationary in nature. A congenital disease may be service connected if it was aggravated during service. 38 C.F.R. § 3.306 (a). On the other hand, a congenital or developmental defect may not be service connected, unless an additional disability due to disease or injury was superimposed upon a defect during service. VAOPGCPREC 82-90 (1990). Accordingly, an addendum opinion is needed to clarify whether the Veteran's maculopathy and status post right eye vitrectomy, membrane peal and focal laser with residual macular scars is a congenital 'disease' or congenital 'defect.' Maculopathy and status post right eye vitrectomy, membrane peal and focal laser with residual macular scars is a congenital 'disease' was not noted at entry into either period of active duty service. To rebut the presumption of soundness, VA would need to establish by clear and unmistakable evidence that: (i) this disease clearly and unmistakably pre-existed service and (ii) it was not aggravated during service. If maculopathy and status post right eye vitrectomy, membrane peal and focal laser with residual macular scars is determined to be a congenital 'defect,' a medical opinion is necessary to determine whether any additional disability due to disease or injury was superimposed on it during service. This issue is remanded for an addendum opinion addresses these questions. 2. Entitlement to service connection for rhinitis (claimed as sinusitis) is remanded. The Veteran asserts that his rhinitis disorder is due to his service in Southwest Asia. At his April 2021 Board hearing, the Veteran testified that prior to service, he did not have allergy symptoms and was never on medication or diagnosed with asthma. His representative indicated that the Veteran endorsed symptoms in his July 2007 post deployment health assessment. This form indeed contains symptoms such as runny nose and fever; however, the Veteran's January 2008 post deployment health reassessment does not report these symptoms. The Veteran's May 2015 VA examination report indicates that his current diagnosis of chronic rhinitis and acute sinusitis are treatable conditions; however, no opinion is provided regarding etiology. As such, a nexus opinion is needed. 3. Entitlement to service connection for BPPV is remanded. The Veteran asserts that his vertigo is directly related to service and possibly secondary to TBI. As noted earlier, TBI is not a service-connected disability and thus, cannot be considered in a secondary claim of service connection. At his Board hearing, the Veteran indicated that his vertigo symptoms were different from his dizziness symptoms, which have been clinically associated with his service-connected migraines. The Veteran's June 2015 VA examination report indicates that he has two types of dizziness: benign paroxysmal positional vertigo (BPPV) and migraine associated with dizziness. The examiner opined that the BPPV was not at least as likely associated with tinnitus, but failed to offer any opinion as to whether it is related to service or a service-connected disorder. As such, an addendum opinion is needed. 4. Entitlement to an earlier effective date of September 6, 2012 for sciatica, right lower extremity is remanded. 5. Entitlement to a higher initial rating for sciatica, right lower extremity is remanded. Regarding the claim of entitlement to an earlier effective date for sciatica, right lower extremity, the Veteran submitted a timely notice of disagreement with the June 2015 rating decision on appeal, but a statement of the case has not yet been issued. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Finally, because a decision on the remanded issue of entitlement to an earlier effective date for sciatica, right lower extremity could significantly impact a decision on the issue of entitlement to a higher initial rating for sciatica, right lower extremity, the issues are inextricably intertwined. A remand of the claim for entitlement to a higher initial rating for sciatica, right lower extremity is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the nature and etiology of the Veteran's eye condition. The claims file, to include a copy of this Remand which contains relevant information, must be reviewed by the examiner. The examiner is to address the following: a) Is this Veteran's maculopathy and status post right eye vitrectomy, membrane peal and focal laser with residual macular scars condition either a congenital 'defect' OR a congenital 'disease.' For VA adjudication purposes, the terms 'disease' and 'defect' are mutually exclusive. 'Disease' generally refers to a condition considered capable of improving or deteriorating, whereas 'defect' generally refers to a structural or inherent abnormalities or conditions that are more or less stationary in nature. b) If it is determined that this Veteran's maculopathy and status post right eye vitrectomy, membrane peal and focal laser with residual macular scars is a congenital 'defect,' then was any other disease or injury superimposed upon the congenital defect as a result of service? c) If it is determined that this Veteran's maculopathy and status post right eye vitrectomy, membrane peal and focal laser with residual macular scars is a congenital 'disease,' then is it clear and unmistakable (i.e. undebatable) it preexisted his active service? If it is clear and unmistakable that it preexisted the Veteran's active service, is it also clear and unmistakable that it was not aggravated (i.e., underwent a permanent increase in severity, beyond the natural progress of the condition) during active service? A complete rationale should be provided for all opinions. 2. Obtain an addendum opinion regarding the nature and etiology of the Veteran's chronic rhinitis and acute sinusitis. The examiner is asked to provide a response to the following: Is rhinitis and/or sinusitis at least as likely as not related to service, including exposure to airborne hazards? A rationale must be provided. 3. Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the Veteran's benign paroxysmal positional vertigo (BPPV). a) The examiner is to opine as to whether BPPV is at least as likely as not related to service. The examiner must provide a rationale to support the opinion. In providing the rationale, the examiner must consider the Veteran's lay report of symptoms and statements, including, that BPPV symptoms present distinctly from that of dizziness. b) Is the Veteran's BPPV at least as likely as not related proximately due to a service-connected disability OR aggravated beyond its natural progression by service-connected disability? 4. Send the Veteran and his representative a statement of the case that addresses the issue of entitlement to an earlier effective date for sciatica, right lower extremity. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issue should be returned to the Board for further appellate consideration. 5. If warranted, following completion of remand directive #4, to include adjudication of entitlement to an earlier effective date for sciatica, right lower extremity, readjudicate the remaining issue of entitlement to a higher initial rating for sciatica, right lower extremity. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Telamour, 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.