Citation Nr: 21005028 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 13-24 904A DATE: January 28, 2021 ISSUES 1. Entitlement to service connection for gastroesophageal reflux disease (GERD). 2. Entitlement to service connection for tension headaches to include as secondary to an acquired psychiatric disorder. 3. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and claimed as a major depressive disorder (MDD), with anxiety, bad dreams, and night sweats. 4. Entitlement to service connection for hypertension. 5. Entitlement to service connection for left foot bone spurs. 6. Entitlement to service connection for right foot bone spurs. 7. Entitlement to service connection for left foot corns. 8. Entitlement to service connection for right foot corns. 9. Entitlement to assignment of a 10 percent evaluation under 38 C.F.R. § 3.324, based on multiple, noncompensable, service-connected disabilities, prior to August 5, 2013. 10. Entitlement to a total disability rating based on individual unemployability (TDIU). REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for tension headaches to include as secondary to an acquired psychiatric disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and claimed as a major depressive disorder (MDD), with anxiety, bad dreams, and night sweats is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for left foot bone spurs is remanded. Entitlement to service connection for right foot bone spurs is remanded. Entitlement to service connection for left foot corns is remanded. Entitlement to service connection for right foot corns is remanded. Entitlement to assignment of a 10 percent evaluation under 38 C.F.R. § 3.324, based on multiple, noncompensable, service-connected disabilities, prior to August 5, 2013 is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1979 to October 1986. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2010 rating decision by the Montgomery, Alabama, Regional Office (RO) of the United States Department of Veterans Affairs (VA). The Veteran testified at an October 2015 hearing held before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. The Board observes that a February 2016 Board Decision and Remand reopened the previously denied claims of service connection for blurred vision, an upper respiratory condition, claimed as allergic rhinitis and sinusitis, and an acquired psychiatric disorder, claimed as a major depressive disorder, anxiety, and night sweats. In Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the Court held that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. Based on the exchange with the Veteran at the hearing, the claims with regard to the lungs and acquired psychiatric disorders were combined and recharacterized. The claim with regard to 38 C.F.R. § 3.324 was recharacterized to reflect that as of August 5, 2013, the Veteran was in receipt of compensation benefits based on a compensable rating for a service-connected disability. Next, an October 2016 rating decision granted service connection for pes planus, hammer toes, degenerative arthritis and hallux valgus of the bilateral feet, chronic sinusitis, left knee strain, right knee strain, and tinea pedis of the bilateral feet. Previously, the Veteran and his representative submitted a February 2019 Informal Hearing Presentation (IHP). The list of issues includes entitlement to service connection for erectile dysfunction. However, the IHP was not clear as to whether the Veteran is attempting to raise a new claim. The RO has not adjudicated this issue. To the extent that the Veteran desires to file a claim for service connection for an erectile disability, he is advised that a complete claim on an application form prescribed by VA regulations is required. 38 C.F.R. § 3.155. Therefore, the Board does not have jurisdiction over it, and it is referred to the RO for appropriate action. 38 C.F.R. § 19.9 (b). Next, the issues were previously remanded by the Board in April 2019 for additional development. These issues are now back before the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D’Aries v. Peake, 22 Vet. App. 97 (2008). During the pendency of his appeals, a March 2020 Rating decision confirmed and continued the previous denial of service connection for diabetes mellitus. Months later, an August 2020 Rating decision granted some claims, confirmed and continued others, and denied several claims unrelated to the current appeals stream. Next, in August 2020, the Veteran filed a VA 21-526EZ Application for Disability Compensation and Related Compensation Benefits. Those service connection and increased rating claims are still before the RO. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2018). By way of background, the Veteran was mailed a May 12, 2016 VA Form 21-4142, Authorization to Disclose Information, and VA Form 21-4142a, General Release for Medical Provider Information, so that VA could obtain treatment information relevant to his claim. VA subsequently made attempts to obtain the requested records from the identified providers. VA informed the Veteran that it is ultimately his responsibility to submit relevant evidence in private treatment records to support his claim. The Board observes that VA has made several attempts to obtain VA treatment records, including from the East and West campuses of the Central Alabama Veterans Health Care System from October 1986 to the present. An October 2018 letter from the Central Alabama Veterans Health Care System shows that a thorough search was conducted, but no records are available prior to 2003 in the system or records. An October 22, 2018 Report of General Information confirmed this finding. Nevertheless, VA treatment records from 2003 were still obtained and associated with the claims file. In addition, throughout 2020, ongoing VA treatment records were associated with the claims file. Importantly, as discussed below, the Veteran and his representative filed a December 2020 Informal Hearing Presentation (IHP). In the IHP, they raise several contentions regarding each issue. Ultimately, as discussed in greater specificity below, a remand was requested for each issue. In light of these explicit requests, although the Board regrets any possible delay, a remand is necessary to ensure that the Veteran is afforded due process, and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. On remand, the Veteran is invited to supplement the record with any private medical opinions. Service Connection To establish service connection a Veteran must generally show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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). 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 distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310 (b). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the Board’s February 2016 Decision and Remand listed the issue of entitlement to service connection for gastroesophageal reflux disease (GERD). However, the issue was never adjudicated or remanded. It will be addressed here. A January 30, 2018 VA Primary Care Note shows in part, “GERD on omeprazole that controls symptoms.” Later, the October 2018 Supplemental Statement of the Case (SSOC) conceded the presence of disability in the VA treatment records. It noted the inability of VA to obtain treatment records prior to 2003, as discussed in the VCAA section above. There was still no nexus. The Veteran through his representative once again raised this issue in the February 2019 IHP. It shows, “Reflux is a common side effect of many pain medications. NSAIDs are notorious for this.” The Board observed in April 2019 that this can be construed as a secondary service connection theory of entitlement. The Veteran was afforded a series of VA medical opinions in December 2019. For GERD, the VA examiner reviewed the entire claims file and performed a physical examination. The VA examiner rendered a negative nexus opinion for direct service connection. She cited the remote onset of GERD 18 years after separation. In a separate document, the VA examiner indicated that she could not determine a baseline of severity based upon medical evidence available. Still, she ultimately opined that GERD is less likely as not aggravated beyond its natural progression due to or the result of service connected conditions. The VA examiner reasoned: While NSAID use can lead to symptoms of GERD, unable to determine chronic NSAID use within current available medical records. Documentation from 12/8/2016 notes “1 month ago came off binge drinking and smoking, reflux since.” Heavy drinking is a risk factor for GERD and can cause damage to the esophageal mucosa. The conditions of groin rash, pes planus, hammer toes, degenerative arthritis and hallux valgus of bilateral feet, limitation of flexion of bilateral knees, tinea pedis, bilateral knee strain, nasal deviation, residuals of fracture nose, chronic sinusitis, hemorrhoids, and pseudofolliculitis barbae are not known causes or risk factors for the development or aggravation of GERD. Therefore the current condition of GERD is less likely as not aggravated beyond its natural progression due to or the result of SC conditions. Next, the Veteran and his representative challenged the conclusions of the VA examiner by way of the December 2020 IHP. They contend: Mr. [Veteran] is currently service connected for chronic sinusitis (0 percent). While there is not absolute proof that sinusitis causes GERD, it is highly likely that the symptoms between sinusitis and GERD are confused with one another as both can be associated with sore throats and chronic coughs. This veteran was treated several times during service for sore throats, sinus problems and an upset stomach. It is very likely that Mr. [Veteran] also suffered from GERD while in service, however, his sinus condition was more prevalent at the time and was likely overlooked. It is appears that Mr. [Veteran] did not know or understand what GERD was and since he had been treated for chronic sinusitis during service and post service, again, his GERD was overlooked. The Veteran’s representative goes on to highlight that medical treatment records show treatment for GERD over “many, many years.” The VA examiner highlights that the Veteran’s lay evidence establishes considerable NSAID use while in service and post service, which establishes their “chronic use.” The Veteran through his representative concludes, “We believe the 2019 C&P to be inadequate as the examiner used the lack of documentation regarding the use of NSAID’s against this veteran. We would recommend that an independent medical opinion be requested should this case be remanded.” Here, the VA examination does not fully address the Veteran’s theory of entitlement as described in the December 2020 IHP. As to any duty to provide an examination and/or seek a medical opinion, the Board notes that in the case of a claim for disability compensation, the assistance provided to the claimant shall include providing a medical examination or obtaining a medical opinion when such examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (noting that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). In Miller v. Wilkie, 32 Vet. App. 249 (2020), the United States Court of Appeals for Veterans Claims (Court) held that when a VA examiner fails to address relevant lay evidence, and the Board fails to find the veteran not credible or not competent to offer that lay evidence, the proper remedy is for VA to obtain a new examination. Therefore, and in light of the representative’s contentions, the Board finds that a remand for a supplemental VA medical opinion is warranted. In addition, the entire claims file should be made available to the VA examiner for review. 2. Entitlement to service connection for tension headaches to include as secondary to an acquired psychiatric disorder is remanded. 3. Entitlement to service connection for an acquired psychiatric disorder, to include post-traumatic stress disorder (PTSD) and claimed as a major depressive disorder (MDD), with anxiety, bad dreams, and night sweats is remanded. The Board incorporates its discussion from the sections above by reference. A remand is necessary for additional development in light of argument submitted by the Veteran and in compliance with the Board’s April 2019 remand directives. These directives included obtaining a VA psychiatric examination. The Board observes that compliance by the Board or the RO with remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Once VA undertakes the effort to provide an examination, it must obtain a fully adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). VA has also not conceded one of the claimed stressors based on in-service personal assault. A stressor statement has been provided. Consequently, a remand is necessary to attempt to corroborate all of the claimed in service stressors, and then a VA examination that complies with the April 2019 remand directives. By way of history, at the October 2015 hearing, the Veteran provided detailed accounts of several confrontations with noncommissioned officers in service, and alleged that such caused or contributed to his psychiatric symptoms. In particular, he described feeling derepressed and being assaulted in service. See October 2015 Hearing Transcript, pp. 25-27. Regarding headaches, he described, “Uh, that I (inaudible) tension headaches from the stress, um, you know, the, I guess the anger inside for how I was treated, which, you know, I guess it just, it’s gonna follow me. It could be in my head, you know, and I, uh, think one reason why I mean to be short patient with people, uh, I look at how people treat me. So uh, I guess I worry a lot and, uh, and, um, cause a lot of unnecessary stress on myself.” Id. at p. 30. Second, the February 2016 remand directives required the VA examiner to consider, “The stressful events described by the Veteran at the October 2015 hearing, and their adequacy to support a psychiatric diagnosis, must be discussed. The examiner must comment on the presence of headaches as a psychiatric/stress symptom, and discuss whether the occurrence of such in service represents the onset of a chronic psychiatric or headache condition.” A private treatment record from Alabama Clinics, received by VA in March 2016 shows a mental status examination with a diagnosis of bipolar disorder. Next, the June 2016 VA psychiatric examination shows that the Veteran does not meet the criteria for PTSD. The VA examiner identified unspecified bipolar-type disorder, cocaine use disorder in early remissions, cannibis use disorder in early remission, and alcohol use disorder in early remission. The VA examiner rendered a negative nexus opinion and noted substance abuse issues. However, it did not fully discuss the Veteran’s hearing testimony, as required by the remand directives. It shows that the Veteran’s stressor is related to personal assault. The VA psychologist ultimately opined in part, “In addition, he cited only a few of the symptoms necessary for a PTSD diagnosis. In light of above-noted considerations, the examiner cannot assert [the Veteran] as likely as not (at least 50/50 probability) suffers from PTSD (DSM-V) or other psychiatric disorders that are caused by or a result of military service.” The following year, the Veteran submitted an August 2017 VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD). It provides two new detailed accounts of personal assault in service. The first involves being punched and breaking his nose while in Germany. The second involves a live fire heavy artillery field exercise, and being pushed/punched so hard that it knocked the wind out of him. There is also a description of being “in shock” because the Veteran could not sleep due to fear of exploding Howitzer bombs, grenades, mortar, and gunfire, all night long for one to two weeks. The February 2019 IHP shows in part, “He also first complained of depression in service and went to the mental health clinic as well.” The Veteran contends that he is entitled to service connection for PTSD, and that he carries a diagnosis. He cites the ongoing VA treatment records, combined with lay and corroborating historical evidence, in support of his claim. With regard to the Veteran’s report of being struck in the nose on May 29, 1984 in service, the Board conceded this in-service stressor in April 2019. The crucial remaining issue is whether there is a nexus between the Veteran’s current psychiatric disability and this stressor. In addition, the Board observes that the current record does not contain independent or objective documentation that corroborates or verifies the Veteran’s additional two claimed in-service stressors (i.e., a hard push, and shock from live fire training). This is also significant inasmuch as the Veteran’s alleged stressor is still considered non-combat in nature. See generally 38 C.F.R. § 3.304. In addition, although the evidence of record currently reflects a claimed diagnosis of psychiatric disorders other than PTSD, that diagnosis is not based on the credible stressors above and is not based on other stressors that have been able to be independently verified. For this Veteran, service connection for PTSD may not be granted in the absence of a verified stressor. If there is no combat experience, there must be independent evidence to corroborate the Veteran’s statements as to the occurrence of a claimed stressor. Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). A Veteran’s testimony, by itself, cannot, as a matter of law, establish the occurrence of a non-combat stressor. Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Moreover, a medical opinion diagnosing PTSD does not suffice to verify the occurrence of a claimed in-service stressor. Cohen v. Brown, 10 Vet. App. 128, 142 (1997); Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996). Service connection for posttraumatic stress disorder requires medical evidence diagnosing the condition in accordance with § 4.125(a) of this chapter; a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). If a posttraumatic stress disorder claim is based on in-service personal assault, evidence from sources other than the veteran’s service records may corroborate the veteran’s account of the stressor incident. Examples of such evidence include, but are not limited to: records from law enforcement authorities, rape crisis centers, mental health counseling centers, hospitals, or physicians; pregnancy tests or tests for sexually transmitted diseases; and statements from family members, roommates, fellow service members, or clergy. Evidence of behavior changes following the claimed assault is one type of relevant evidence that may be found in these sources. Examples of behavior changes that may constitute credible evidence of the stressor include, but are not limited to: a request for a transfer to another military duty assignment; deterioration in work performance; substance abuse; episodes of depression, panic attacks, or anxiety without an identifiable cause; or unexplained economic or social behavior changes. VA will not deny a posttraumatic stress disorder claim that is based on in-service personal assault without first advising the claimant that evidence from sources other than the veteran’s service records or evidence of behavior changes may constitute credible supporting evidence of the stressor and allowing him or her the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. VA may submit any evidence that it receives to an appropriate medical or mental health professional for an opinion as to whether it indicates that a personal assault occurred. 38 C.F.R. § 3.304(f)(5). The June 2020 Supplemental Statement of the Case (SSOC) shows in part, “The available medical evidence is insufficient to confirm a link between current symptoms and an in-service stressor.” This is confusing, as the Board conceded one stressor, supra. Nevertheless, the SSOC identified that an August 7, 2019 VA VA Form 21-0781 has not been completed and returned. The Board observes that there is returned mail in the claims file from August 10, 2020. Next, the December 2020 IHP contains considerable argument related to VA’s duty to assist in developing this claim. The IHP reads in part, “This veteran has been consistent regarding his stressors: his issues with his leadership who he felt threatened him and his recurrent disciplinary problems. All of this appears to have been overlooked by the VA or rather, brushed aside as Mr. [Veteran] did not receive any treatment while in service or within one year post service. There are markers within this veteran’s STR’s which point to mental health concerns.” On remand, the Veteran will be afforded another opportunity to assist the RO in fully corroborating his claimed stressors. A new notification letter should be provided to the Veteran which details requirements pertaining to his claim to service connection for PTSD based on non-combat stressors. If no response is received, the claim will be adjudicated based upon the evidence of record. Here, in April 2019 Remand for the claimed acquired psychiatric disorder, the Board ordered that the Veteran be provided with a new VA psychiatric examination that addresses his contentions, including those contained in the August 2017 Statement. 38 U.S.C. § 5103A (d); McLendon, Barr, both supra. The VA psychiatric examination was required to specifically discuss the nature and etiology of unspecified bipolar disorder, including a claimed onset in service as a result of personal assault. This development has not been fully completed. The December 2020 IHP reads in part, “Should the Board feel otherwise, we ask that they remand this case for further development. We also recommend that an independent medical opinion be obtained regarding this veteran’s multiple mental health conditions.” Compliance by the Board or the RO with remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Consequently, a remand is necessary to fully develop his claim and then obtain a VA psychiatric examination that complies with the April 2019 Remand directives. Third, turning to the issue of service connection for tension headaches, the Board observes that the Veteran testified that his tension headaches are related to anger worrying, and stress. This can be construed as a claim for secondary service connection for tension headaches. By way of background, the previous February 2016 remand directives required, “The examiner must comment on the presence of headaches as a psychiatric/stress symptom, and discuss whether the occurrence of such in service represents the onset of a chronic psychiatric or headache condition.” Next, a February 2018 VA examination shows a diagnosis of tension headaches in February 2018. However, it also shows a history of onset back to 1985. There is no nexus medical opinion. On remand, this inconsistency should be resolved. Later, in December 2019, the Veteran was afforded a VA headaches medical opinion. The VA examiner rendered a negative nexus opinion for direct and presumptive service connection. She cited the remote onset of the disease entity 17 years after separation. The VA examiner also ultimately concluded that there was no aggravation beyond the condition’s natural progression. The VA examiner reasoned, “Less likely that condition of tension headaches is aggravated beyond its natural progression. Condition is currently only treated with OTC medications.” Importantly, a separate medical opinion document contains a positive nexus opinion for proximate cause for headaches. The rationale reads: Research has shown that there are strong links between tension headaches and mental disorders, including depression and anxiety. Documentation from 7/8/2009 notes claimant stating “believes his headache is related to depression problem.” Documentation from 5/2/2005 notes headaches occurring when working under stress. At the October 2015 hearing, Veteran claimed having anger that caused increased stress. Therefore it is at least as likely as not that the current condition of tension headaches is at least as likely as not proximately due to or the result of SC psychiatric condition. Based upon this positive nexus opinion, the issue of service connection for tension headaches is intertwined with the ongoing requested development related to an acquired psychiatric disorder. Consequently, this issue is also remanded to the AOJ pending the outcome of the service connection for an acquired psychiatric disorder claim. 4. Entitlement to service connection for hypertension is remanded. The Board incorporates its discussion from the sections above by reference. “Hypertension” refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm Hg systolic and 90 mm Hg diastolic to as high as 200 mm Hg systolic and 110 mm Hg diastolic as reflective of hypertension. See Dorland’s Illustrated Medical Dictionary, 896 (32nd ed. 2012). Similarly, for VA rating purposes, the term “hypertension” means that the diastolic blood pressure is predominantly 90 mm Hg or greater. The term “isolated systolic hypertension” means that the systolic blood pressure is predominantly 160 mm Hg or greater with a diastolic blood pressure of less than 90 mm Hg. See 38 C.F.R. § 4.104 , DC 7101, Note (1). For VA purposes, hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id. Hypertension is a recognized chronic disease, and as such, additional presumptive theories of entitlement are relevant in addition to direct service connection. See 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). By way of background, VA treatment records from as early as August 20, 2004 consistently show a diagnostic impression of hypertension. Recently, a January 30, 2018 VA Primary Care Note shows, “Hypertension: well controlled, restart losartan, d/c HCTZ, low sodium diet.” The February 2019 IHP shows, “Hypertension and neuropathies are known complications of apnea.” This assertion is not attributed to any particular medical source or examiner’s findings as they relate to this Veteran. Next, the Veteran was afforded a December 2019 VA medical opinion. The VA examiner reviewed the entire claims file and performed a physical examination. There are separate medical opinion documents for this condition. The VA examiner rendered a negative nexus opinion for direct and presumptive service connection. She cited the remote onset of the disease entity 17 years after separation. The VA examiner indicated, “THE CLAIMED CONDITION IS LESS LIKELY THAN NOT (less than 50 percent probability) PROXIMATELY DUE TO OR THE RESULT OF THE VETERAN’S SERVICE CONNECTED CONDITION.” The VA examiner also opined that hypertension was not aggravated beyond its natural progression. The VA examiner reasoned: While NSAID use can lead to higher blood pressure, unable to determine chronic NSAID use within current available medical records. The conditions of groin rash, pes planus, hammer toes, degenerative arthritis and hallux valgus of bilateral feet, limitation of flexion of bilateral knees, tinea pedis, bilateral knee strain, nasal deviation, residuals of fracture nose, chronic sinusitis, hemorrhoids, and pseudofolliculitis barbae are not known causes or risk factors for the development or aggravation of HTN. Therefore the current condition of HTN is less likely as not aggravated beyond its natural progression due to or the result of SC conditions. Next, in the December 2020 IHP, the Veteran through his representative challenges the adequacy of the December 2019 VA examination with medical opinion. They cite changes in blood pressure during service, including readings at separation showing a “pre-hypertensive phase.” The Veteran also avers: It is important to note that this veteran has chronic sinusitis and repeatedly took over the counter (OTC) medication to treat this long term disability in addition to the long history of the NSAID’s this veteran took for his other conditions. The previous C&P’s do not appear to take this veteran’s sinusitis disability into play when determining a nexus between military service to present day with regards to this veteran’s diagnosis of HTN. The examiner from the 2019 C&P also used the lack of medical documentation from the period of discharge to 2003 as a reason to provide a negative opinion. The Veteran through his representative requests that if a grant of service connection is not possible, the issue should be remanded for a new medical opinion that fully addresses the evidence. We find this argument persuasive to the extent a supplemental VA medical opinion is necessary for the VA examiner to consider the evidence highlighted by the Veteran’s representative. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Therefore, a remand is warranted. 5. Entitlement to service connection for left foot bone spurs is remanded. 6. Entitlement to service connection for right foot bone spurs is remanded. 7. Entitlement to service connection for left foot corns is remanded. 8. Entitlement to service connection for right foot corns is remanded. The Board incorporates its discussion from the sections above by reference. By way of background, the issues of service connection for bone spurs and corns of the bilateral feet were remanded by the Board in February 2016 as part of a broader remand for a VA foot examination. The remand directives included, “Review the claims file to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If any of the benefits sought remain denied, issue an appropriate supplemental statement of the case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order.” (emphasis added). A June 2016 VA foot conditions examination shows in part, “The Veteran has a diagnosis of spurs or corns of the feet.” Next, an October 2016 rating decision granted service connection for pes planus, hammer toes, degenerative arthritis and hallux valgus of the bilateral feet is granted with an evaluation of 30 percent effective April 9, 2009. The October 2018 Supplemental Statement of the Case (SSOC) does not reflect consideration of these issues, which were not addressed in the October 2016 rating decision. The February 2019 IHP reflects the issues of service connection for left foot corns, and right foot corns, while omitting bilateral bone spurs. Next, in April 2019, the Board previously found that a remand was necessary for additional development in compliance with the Board’s February 2016 remand directives and the governing law. See Stegall, D’Aries, both supra; 38 C.F.R. §§ 19.31, 19.37. The Veteran was subsequently issued the June 2020 SSOC informing him of the evidentiary requirements necessary to substantiate his claim. In response, by way of the December 2020 IHP, the Veteran through his representative presents new evidentiary and duty to assist arguments. First, the Veteran challenges the adequacy of the August 2016 VA foot conditions examination. The Veteran asserts, “This C&P also stated that this veteran also had bone spurs and corns on his feet, however, did not give a diagnosis date for either. These conditions were also not included in the medical opinion or VA Decision of October 2016 – only the first three conditions which were combined into one service connected disability. It is unclear why these conditions were not previously included in the granting of service connection for this veteran’s bilateral feet.” In addition, the Veteran’s representative contends, “The fact that Mr. [Veteran] has degenerative arthritis must be taken into account with regards to his bilateral bone spurs. There does not appear to have an additional C&P or medical opinion provided for the feet of this veteran since 2016.” The Veteran’s representative cites a link from the Mayo Clinic in support of this assertion. The Veteran through his representative requests a remand for an “updated” VA foot examination with medical opinion to consider all claimed conditions. The Board finds these arguments persuasive to the extent there is additional evidence to be considered by the VA examiner in rendering a complete medical opinion. The VA examiner should provide a date of onset for all identified disease entities of the feet, to the extent possible. Therefore, a remand for a supplemental VA examination with medical opinion is warranted. 38 U.S.C. § 5103A (d); McLendon v. Nicholson, 20 Vet. App. 79 (2006). 9. Entitlement to assignment of a 10 percent evaluation under 38 C.F.R. § 3.324, based on multiple, noncompensable, service-connected disabilities, prior to August 5, 2013 is remanded. 10. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. The Board incorporates its discussion from the sections above by reference. Consistent with its approach in the February 2016 Decision and Remand, the Board notes that entitlement to these benefits is dependent upon consideration of the impact of service-connected disabilities on a Veteran’s employability. The Veteran through his representative specifically requests that the Board continue to follow this approach in the December 2020 IHP. Therefore, while the above development may not bear directly upon the matters, they are inextricably intertwined with the pending claims. It would be premature to adjudicate either claim prior to resolution of the other issues. Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). Therefore, these issues are also remanded. The matters are REMANDED for the following action: 1. If the Veteran identifies other evidence, obtain updated copies of the Veteran’s VA treatment records, and associate them with the Veteran’s claims folder. 2. Provide the Veteran with appropriate notice advising that an alleged in-service personal assault stressor may be corroborated by evidence from sources other than his service records. Provide the Veteran with examples of relevant alternative sources of such evidence as listed in 38 C.F.R. § 3.304 (f)(5). Allow an appropriate time for the Veteran to respond after receipt of this notice. 3. Inform the Veteran that he may submit an updated stressor statement on a VA Form 21-0781a Statement in Support of Claim for Service Connection for PTSD Secondary to Personal Assault providing any additional details he wishes to be considered regarding his in-service stressors. If no additional evidence is received, the case will be adjudicated based upon the evidence of record. 4. Make another attempt to corroborate the Veteran’s claimed in-service stressors not yet conceded of (1) being pushed so hard that it knocked the wind out of him, and (2) being in shock in service during live fire training. If more details are needed, contact the Veteran to request the information. See December 2020 Informal Hearing Presentation (IHP). 5. Please schedule the Veteran for a VA examination to determine the nature and etiology of any gastroesophageal reflux disease (GERD). The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. The VA examiner should comment on the Veteran’s lay reports of “chronic” NSAID use in service and post service, along with his reported history of GERD. See December 2020 IHP. The VA examiner should also opine whether any diagnosed GERD is proximately due to, the result of, or aggravated by the Veteran’s service-connected disabilities, including service-connected sinusitis. The examiner should provide a rationale for all opinions expressed. 6. After the development related to PTSD based upon personal assault noted above has been completed, please schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed acquired psychiatric disorder, to include PTSD, a major depressive disorder (MDD), and unspecified bipolar-type disorder. This examination must be conducted by a VA psychiatrist or psychologist. The claims file and a copy of this remand must be made available to the examiner in conjunction with the requested examination, and the examiner should indicate that the claims file was reviewed. All necessary tests should be conducted, and the Veteran’s complaints should be recorded in full. The VA examiner should answer the following: (i) What are the Veteran’s current psychiatric disorders? In particular, has the Veteran had PTSD, MDD, or a bipolar-type disorder at any time during the appeals period? (ii) Is it at least as likely as not (a probability of 50 percent or greater) that a diagnosed non-PTSD psychiatric disorder began in service, was caused by service, or is otherwise related to active military service? Attention is directed to private treatment records from Alabama Clinics, received by VA in March 2016, showing a diagnosis of bipolar disorder. (iii) If PTSD is diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not that the Veteran’s disability is causally related to any corroborated stressor during his military service, whether a verified in-service stressor is adequate to support a diagnosis of PTSD, and whether the current PTSD symptoms relate to the stressor(s). (iv) If PTSD is diagnosed based upon the claimed in-service personal assault stressor, the examiner should provide an opinion as to whether it is at least as likely as not that the in-service personal assault occurred, and should identify the nature of the evidence used to reach that opinion. To date, the Board has conceded the stressor of in-service assault in May 1984 resulting in a nasal fracture, supra. In addressing these questions, please discuss the Veteran’s lay assertions of record, to include any stressor statements submitted into evidence (e.g., August 2017 VA Form 21-0781, Statement in Support of Claim for Service Connection for Post-Traumatic Stress Disorder (PTSD). Attention is generally invited to the Veteran’s hearing testimony. See October 2015 Hearing Transcript, pp. 25-27. In rendering the requested opinions, the examiner must be aware that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a particular basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The VA examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The VA examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. 7. Please schedule the Veteran for a VA examination to determine the nature and etiology of any hypertension. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. The VA examiner should also opine whether any diagnosed hypertension is proximately due to, the result of, or aggravated by the Veteran’s service-connected disabilities. The VA examiner should comment on blood pressure readings in service. The VA examiner should also comment any medications taken for hypertension and/or sinusitis. See October 2015 Hearing Transcript, p. 28; see also December 2020 IHP. The examiner should provide a rationale for all opinions expressed. 8. Please schedule the Veteran for a VA examination to determine the nature and etiology of any for left foot bone spurs, right foot bone spurs, left foot corns, and right foot corns. The claims file should be made available to the VA examiner. For each diagnosed disability, the VA examiner is requested to answer whether it is at least as likely as not (a 50 percent or greater probability) that the disability was incurred in or is otherwise related to the Veteran’s active military service. Attention is invited to the December 2020 IHP in which the Veteran claims to have sought treatment for various foot conditions in service. The VA examiner should also opine whether any diagnosed foot disability is proximately due to, the result of, or aggravated by the Veteran’s service-connected disabilities, including degenerative arthritis. Related to this, the VA examiner should comment on the Mayo Clinic link cited in the December 2020 IHP. The examiner should provide a rationale for all opinions expressed. 9. All examiners should comment on the impact of the service connected disabilities, individually and in combination, on the Veteran’s ability to function in work-related tasks (e.g., sitting, standing, walking, bending, stooping, lifting, cognitive functioning, attendance, etc.). Full and complete rationales are required for all opinions expressed. 10. After completing all necessary development, adjudicate the Veteran’s claims for entitlement to assignment of a 10 percent evaluation under 38 C.F.R. § 3.324, based on multiple, noncompensable, service-connected disabilities, prior to August 5, 2013, and a TDIU, in light of all pertinent evidence and legal authority. 11. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his representative an appropriate supplemental statement of the case (SSOC). Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Bodi, 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.