Citation Nr: 22010562 Decision Date: 02/24/22 Archive Date: 02/24/22 DOCKET NO. 17-15 523 DATE: February 24, 2022 ORDER 1. The application to reopen the claim for service connection for a bilateral hearing loss disability is denied. 2. The application to reopen the claim for service connection for active sarcoidosis is denied. 3. The application to reopen the claim for service connection for a right foot disability is granted. REMANDED 4. Entitlement to service connection for hypertension is remanded. 5. Entitlement to service connection for a right hip disability is remanded. 6. The reopened claim of entitlement to service connection for a right foot disability is remanded. FINDINGS OF FACT 1. In an unappealed May 2012 rating decision, the Regional Office (RO) denied service connection for a bilateral hearing loss disability based on a finding that the Veteran did not have a bilateral hearing loss disability for VA purposes. 2. Evidence submitted since the May 2012 rating decision does not relate to an unestablished fact necessary to substantiate the claim for service connection for a bilateral hearing loss disability. 3. In an unappealed May 1999 rating decision, the RO denied service connection for active sarcoidosis based on a finding that there was no relationship between the Veteran's active sarcoidosis and his military service. 4. In an unappealed August 2013 rating decision, the RO denied reopening the claim for service connection for active sarcoidosis based on the finding that there still was no evidence of a relationship between the post-service diagnosis of sarcoidosis and service. 5. Evidence submitted since the August 2013 rating decision does not relate to an unestablished fact necessary to substantiate the claim for service connection for active sarcoidosis. 6. In an unappealed August 2013 rating decision, the RO denied service connection for a right foot disability based on a finding that there was no evidence of a relationship between the post-service diagnosis of bilateral hallux valgus with degenerative changes and service. 7. Evidence submitted since the August 2013 rating decision relates to an unestablished fact necessary to substantiate the claim for service connection for a right foot disability. CONCLUSIONS OF LAW 1. The May 2012 rating decision denying service connection for a bilateral hearing loss disability is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103 2. New and material evidence has not been received to reopen the claim for service connection for a bilateral hearing loss disability. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(a), 20.1103. 3. The May 1999 rating decision denying service connection for active sarcoidosis is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 4. The August 2013 rating decision denying the application to reopen the claim for service connection for active sarcoidosis is final. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(a), 20.1103. 5. New and material evidence has not been received to reopen the claim for service connection for active sarcoidosis. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156(a), 20.1103. 6. The August 2013 rating decision denying service connection for a right foot disability is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 7. The criteria for reopening the claim for service connection for a right foot disability based on new and material evidence have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army from August 1976 to June 1982. While these matters were on appeal, the Veteran died in August 2017. The appellant was substituted as the claimant for all of the claims that were pending at the time of the Veteran's death. See 38 U.S.C. §§ 5121, 5121A; 38 C.F.R. § 3.1000. In February 2020, the appellant provided testimony at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. At the Board hearing, the undersigned Veterans Law Judge gave the appellant and her agent a 90-day extension. During the extension period, the appellant submitted additional evidence for consideration. The appellant also had a claim for service connection for cause of the Veteran's death pending before the Board. However, during the pendency of the appeal, the Regional Office (RO) granted the claim in an August 2020 rating decision. As this is a full grant of the claim, it is no longer part of the current appeal before the Board. New and Material Evidence Prior unappealed decisions of the Regional Office (RO) are final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. The Board does not have jurisdiction to consider a claim that has become final before it determines that new and material evidence has been presented, irrespective of what the regional office may have determined with respect to new and material evidence. Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). If, however, new and material evidence is presented or secured with respect to a claim that has been disallowed, VA shall reopen the claim and review the former disposition of the claim. Manio v. Derwinski, 1 Vet. App. 145 (1991). New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence means existing evidence that, by itself or considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. New and material evidence need not be received as to each previously unproven element of a claim in order to justify reopening thereof; the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Shade v. Shinseki, 24 Vet. App. 110, 11720 (2010). 1. New and material evidence for a bilateral hearing loss disability The appellant contends that the Veteran submitted new and material evidence sufficient to reopen the claim for service connection for a bilateral hearing loss disability. The claim for service connection for a bilateral hearing loss disability was initially considered and denied by the RO in a May 2012 rating decision. At the time of the May 2012 rating decision, the evidence of record consisted of the Veteran's service treatment records, the Veteran's Application for Compensation and/or Pension, a January 2012 Statement in Support of Claim, and a March 2012 VA examination report. In the March 2012 VA examination report, it shows the Veteran had normal hearing. Furthermore, the Veteran's puretone thresholds did not show that the Veteran had a bilateral hearing loss disability for VA purposes. See 38 C.F.R. § 3.385. Thus, the RO denied the claim due to no evidence of a bilateral hearing loss disability for VA purposes. The Veteran was notified of that decision and of his appellate rights. The Veteran did not submit a notice of disagreement or new and material evidence within one year of the notification letter. Thus, the May 2012 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Since the May 2012 rating decision, the Veteran continued to report that he began having hearing loss in service. Additional evidence was added to the file; including additional VA treatment records, various VA examinations not related to the Veteran's hearing loss claim, a death certificate, and the appellant's Board hearing testimony. Unfortunately, the Veteran passed away during the pendency of his appeal. At the February 2020 hearing, the appellant testified that the Veteran was a canon crew member, and she was sure that while the Veteran was out there, he had some hearing loss. The appellant stated that she did not know the level of the Veteran's hearing loss at the time of his death. Additionally, the appellant submitted a death certificate in May 2020 that included hearing loss as a significant condition contributing to death but not resulting in the underlying cause. The Board notes that the appellant's statements and the death certificate are new evidence, as they were not associated with the claims file at the time of the May 2012 rating decision denial. However, while the appellant testified that she believes the Veteran had a bilateral hearing loss disability and the death certificate documented that the Veteran had a hearing loss disability, there is no evidence of record that raises a reasonable possibility of substantiating the claim by documenting the puretone threshold to establish that the Veteran's hearing loss qualified as a bilateral hearing loss disability for VA purposes. Thus, the evidence submitted since the May 2012 rating decision is not material. Accordingly, the Board finds that new and material evidence has not been received to reopen the claim for service connection for a bilateral hearing loss disability. Therefore, the application to reopen the previously-denied claim for service connection for a bilateral hearing loss disability is denied. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. New and material evidence for active sarcoidosis The appellant contends that the Veteran submitted new and material evidence sufficient to reopen the claim of entitlement to service connection for active sarcoidosis. The claim for service connection for active sarcoidosis was initially considered and denied by the RO in a May 1999 rating decision due to no evidence indicating that the active sarcoidosis was incurred in or aggravated by the Veteran's military service. At the time of the May 1999 rating decision, the evidence of record consisted of the Veteran's service treatment records, VA medical treatment records, and a December 1998 VA examination. The December 1998 VA examination shows that the Veteran was diagnosed with active sarcoidosis. However, the RO found that the evidence did not show that sarcoidosis had its onset during service, that it manifested within one year of service discharge, or there was a relationship between the active sarcoidosis and the Veteran's military service. Thus, the evidence lacking at that time was evidence of an in-service disease or injury and a nexus between the post-service diagnosis of active sarcoidosis and service. The Veteran was notified of that decision and of his appellate rights. The Veteran did not submit a notice of disagreement or new and material evidence within one year of the notification letter. Thus, the May 1999 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. In January 2012, the Veteran filed an application to reopen the claim for service connection for sarcoidosis. An August 2013 rating decision denied the application to reopen based on a finding that the Veteran had not submitted new and material evidence. At the time of the August 2013 rating decision, additional evidence was considered, including VA treatment records, private medical treatment records, copies of service treatment records, and a June 2012 Statement in Support of Claim. The RO found that there still was no evidence of in-service disease or injury or a nexus between the post-service diagnosis of sarcoidosis and service. The Veteran did not submit a notice of disagreement or new and material evidence within one year of the notification letter. Thus, the August 2013 rating decision became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Since the August 2013 rating decision, the Veteran continued to assert his active sarcoidosis was related to service. Relevant evidence added to the file consists of copies of service treatment records, VA treatment records, and the application to reopen the claim. Unfortunately, the Veteran passed away during the pendency of his appeal. During the Board hearing, the appellant testified that the Veteran had a positive tuberculosis test during his time in the military, and there could be a relationship between tuberculosis and sarcoidosis. While this evidence is new, the appellant does not offer any other evidence showing there is a relationship between the two diseases. The evidence added to the file also does not establish by competent evidence of a nexus between the post-service diagnosis of sarcoidosis and service. The Board finds this is not material evidence and does not raise a reasonable possibility of substantiating the claim. Accordingly, the Board finds that new and material evidence has not been received to reopen the claim for service connection for active sarcoidosis. Therefore, the application to reopen the previously denied claim is denied. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. New and material evidence for a right foot disability The appellant contends that the Veteran submitted new and material evidence sufficient to reopen the claim of entitlement to service connection for a right foot disability. The claim for service connection for a right foot disability was initially denied in an August 2013 rating decision based on a finding that there was no nexus between the Veteran's right foot disability and service. The Veteran was notified of this determination in an August 2013 letter, which included information about the Veteran's appeal rights. The Veteran did not appeal this decision. Thus, the August 2013 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. Since the August 2013 rating decision, new evidence has been added to the claims file. A review of the record shows that in a March 2020 letter from Kimberly Schat, A.P.R.N.-C.N.P. stated that the Veteran's service-connected right knee osteoarthritis exacerbated and contributed to his right hip and right foot pain. This evidence is new because it has not been previously submitted. This evidence is also material because it pertains to the bases for the prior denial, that is, whether the Veteran's right foot disability was incurred in service or is secondary to a service-connected disability, and raises a reasonable possibility of substantiating the claim. For these reasons, the Board finds that new and material evidence has been received to reopen service connection for a right foot disability. See 38 C.F.R. § 3.156(a). REASONS FOR REMAND 4. Entitlement to service connection for hypertension At the February 2020 Board hearing, the appellant stated that she was not aware of when the Veteran's hypertension was diagnosed, but she knows he was taking blood pressure medication. In March 2020, the appellant submitted a letter from Dr. Timothy L. Moore, D.O., wherein he wrote that the Veteran's service-connected tinnitus contributed to and aggravated his severe hypertension, congestive heart failure, and hypertensive cardiovascular disease. Dr. Moore stated that the appellant reported that the Veteran's tinnitus caused distress, depression, anxiety, frequent mood swings, sleep disturbances, irritability, frustration, poor concentration, and pain. Additionally, Dr. Moore wrote that research showed an association between anxiety, depression, and posttraumatic stress disorder and the development and/or aggravation of coronary artery disease. As the appellant now asserts that the Veteran's hypertension is secondary to the service-connected tinnitus and has submitted evidence that there may be relationship between hypertension and tinnitus, the Board finds that a medical opinion is necessary in order to decide the claim. The Board notes that VA has already obtained an opinion as to whether hypertension had its onset in service or was otherwise related to service. 5. Entitlement to service connection for a right hip disability The appellant submitted a May 2020 letter from Kimberly Schat, A.R.N.P.-C.N.P., wherein she wrote that the Veteran's service-connected osteoarthritis of the right knee exacerbated and contributed to his right hip and right foot pain. Ms. Schat stated that within a reasonable degree of medical certainty, it is in her professional medical opinion that the Veteran's right hip condition leading to pain, restricted mobility, and weakness; and right foot degenerative joint disease are more likely than not secondary to the service-connected right knee osteoarthritis. The Board finds this opinion to be inadequate, as it does not address the conflicting medical evidence that suggests the Veteran's right hip disability was related to his neurosarcoidosis and not the service-connected right knee disability. Thus, the Board finds that an opinion is necessary to determine if the Veteran's right hip disability is related to a service-connected disability. 6. Entitlement to a right foot disability As stated above, the appellant submitted a May 2020 letter from Kimberly Schat, A.R.N.P.-C.N.P., wherein she wrote that the Veteran's service-connected osteoarthritis of the right knee exacerbated and contributed to his right hip and right foot pain. Ms. Schat stated that within a reasonable degree of medical certainty, it is in her professional medical opinion that the Veteran's right hip condition leading to pain, restricted mobility, and weakness; and right foot degenerative joint disease are more likely than not secondary to the service-connected right knee osteoarthritis. Thus, as the Veteran's claim is reopened, the Board finds that an opinion is necessary to determine if the Veteran's right foot disability is related to the service-connected right knee disability. The Board notes that VA has already obtained an opinion as to whether the right foot disability had its onset in service or is otherwise related to service. Accordingly, the claims are REMANDED for the following actions: 1. Obtain a medical opinion from an appropriate examiner to determine if hypertension was caused or aggravated by the service-connected tinnitus. The examiner should be provided access to the claims file. The agency of original jurisdiction is asked to provide the examiner a copy of the below facts. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served in active duty from August 1976 to June 1982. The Veteran died in August 2017 due to congestive heart failure due to or as a consequence of hypertensive cardiovascular disease. See VBMS entry with document type, "Death Certificate," receipt date 09/18/2017, item 34. At the time of the Veteran's death, he was service connected for migraine headaches, osteoarthritis of the right knee, tinnitus, and onychomycosis. In May 2020, the appellant, the Veteran's surviving spouse, submitted an amended death certificate that showed tinnitus and hearing loss were added as an "other significant condition contributing to death but not resulting in the underlying cause given in PART I." See VBMS entry with document type, "Death Certificate," receipt date 05/20/2020, item 35. The Veteran was not service connected for hearing loss during his lifetime. The Veteran's surviving spouse believes that the service-connected tinnitus caused or aggravated the Veteran's hypertension. In January 1980, while in service, the Veteran complained of high blood pressure. The examiner documented noted to rule out high blood pressure. Readings were taken in three ways, the highest noted were 120/80 and 110/72. See VBMS entry with document type, "STR - Medical," receipt date 11/24/2015, p. 9. The October 1980 Report of Medical Examination shows that the Veteran had a blood pressure reading of 120/80. See VBMS entry with document type, "STR - Medical," receipt date 11/24/2015, pp. 38-39 (item 57). The corresponding October 1980 Report of Medical History shows that the Veteran reported a positive history of having high or low blood pressure. See VBMS entry with document type, "STR - Medical," receipt date 11/24/2015, pp. 36-37 (item 11, first column). The January 1991 Report of Medical Examination, which was completed approximately nine years following service discharge, shows that the Veteran was found to be clinically normal in all areas. His blood pressure reading was 116/80. See VBMS entry with document type, "STR," receipt date 04/03/1997, pp. 16-17 (item 57). The corresponding January 1991 Report of Medical History shows that the Veteran denied a history of having high or low blood pressure. See VBMS entry with document type, "STR," receipt date 04/03/1997, pp. 19-20 (item 11, first column). A May 1992 United States Civil Services Commission Certificate of Medical Examination shows that the Veteran had a blood pressure of 100/70. The examiner concluded that the Veteran had no limiting conditions for the job of store worker. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 08/31/1998, with "#2" in the subject field, pp. 3-4. In August 1997, the Veteran was seen for mediastinal adenopathy and cough. When addressing the Veteran's past medical history, the examiner noted he had allergies and that his current medications were Motrin and Erythromycin. When addressing the Veteran's past medical history, the examiner wrote, "Significant medical problems, none." See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 08/31/1998, with "#1" in the subject field, p. 9. A November 1998 letter from Petra Gurtner, M.D., notes that the Veteran's past medical history was negative except for neurosarcoidosis. The examiner documented that the Veteran was taking Prednisone, Fosamax, methotrexate, folic acid, calcium, vitamin D, and trazadone. The examiner documented the Veteran's family history was positive for hypertension and stroke. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 06/19/2012, pp. 1-2. A December 1998 VA examination report shows that when the Veteran was being evaluated for sarcoidosis, the examiner documented that the Veteran had been diagnosed as "hypertensive in 1995. He was started on lisinopril and continues on this medication at present." See VBMS entry with document type, "VA Examination," receipt date 12/18/1998, with "#1" in the subject field, pp. 3-4. A March 2006 private medical record shows that the Veteran was seen with complaints of chest pain for three days and night sweats. The Veteran denied shortness of breath. Cardiac Risk Factors were listed within the "HISTORY OF PRESENT ILLNESS," which included, "HTN," which was not circled. Under "MEDICAL AND SOCIAL HISTORY," when addressing the "Med Hx," it included "HTN," which was not circled, and the examiner checked the box that showed he or she had reviewed the Veteran's medical history with him. When addressing medications, the examiner wrote none by putting a circle with a line through it. The Veteran's blood pressure was documented as 130/93 within the "PHYSICAL EXAM." The diagnoses entered were acute myocardial infarction, chest wall pain, costochondritis, pneumothorax, and pneumonia. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 06/17/2013, with "#2" in the subject field, pp. 8-9. While the December 1998 VA examination report documented the Veteran had been hypertensive since 1995, the March 2006 private treatment records would seem to show that the Veteran did not have hypertension, since hypertension was not circled as a risk factor or as part of the Veteran's medical history. An April 2009 private medical record shows the Veteran was there for a follow-up visit regarding sarcoidosis. When addressing the Veteran's medications, the examiner listed ASA, multivitamins, and Restoril. His blood pressure was 95/58. See VBMS entry with document type, "Medical Treatment Record Government Facility," 06/17/2013, with "#1" in the subject field, p. 36. At a March 2012 VA audiological evaluation, the Veteran reported that tinnitus had begun in 1978. See VBMS entry with document type, "C&P Exam," receipt date 03/29/2012, with "#1 Audiology" in the subject field, p. 5. An August 2012 private medical record shows that the Veteran was seen on follow up for interstitial lung disease. When addressing the Veteran's past medical history, the examiner documented neurosarcoidosis in 1996 and pulmonary sarcoidosis in November 2007. His current medications were prednisone and pravastatin. His blood pressure was documented as 106/74. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 06/17/2013, with "#2" in the subject field, p. 36. A January 2016 VA examination shows that the examiner entered a diagnosis of hypertension and wrote the date of diagnosis was "1970," which appears to have been based on the Veteran reporting that fact. See VBMS entry with document type, "C&P Exam," receipt date 01/12/2016, with "DBQ CARDIO" in the subject field, pp. 1 3. The January 2016 examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner noted that he was unable to find any records of hypertension or treatment for the condition during service. The examiner stated the Veteran's blood pressure readings were normal on physical examination and he reported the Veteran was taking medication for hypertension but was unable to remember the name of the medication. See VBMS entry with document type, "C&P Exam," receipt date 01/12/2013, with "DBQ MEDICAL OPINION hypertension" in the subject field, p. 2. In March 2020, Timothy L. Moore, D.O., opined that the Veteran's tinnitus contributed to and aggravated the Veteran's severe hypertension, congestive heart failure, and hypertensive cardiovascular disease. See VBMS entry with document type, "Medical Treatment Record Non-Government Facility," receipt date 05/26/2020, with "#1" in the subject field. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions: (a.) Was the Veteran's hypertension caused by the service-connected tinnitus? Please explain upon what facts, medical principles, and/or medical literature the opinion is based. (b.) If the answer to (a.) is negative, was the Veteran's hypertension aggravated by the service-connected tinnitus? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please explain upon what facts, medical principles, and/or medical literature the opinion is based. (c.) If the examiner finds that tinnitus caused an increase in severity of the Veteran's hypertension that is not due to the natural progress of the disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for hypertension prior to aggravation. If the examiner is unable to establish a baseline for the hypertension prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. Obtain a medical opinion from an appropriate examiner to determine if the right hip disability was caused or aggravated by the service-connected right knee disability. The agency of original jurisdiction is asked to provide the examiner a copy of the below facts. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served in active duty from August 1976 to June 1982. The Veteran died in August 2017 due to congestive heart failure due to or as a consequence of hypertensive cardiovascular disease. See VBMS entry with document type, "Death Certificate," receipt date 09/18/2017, item 34. At the time of the Veteran's death, he was service connected for migraines, osteoarthritis of the right knee, tinnitus, and onychomycosis. The Veteran's surviving spouse believes that the service-connected right knee disability caused or aggravated a right hip disability. The records show that the veteran was diagnosed with sarcoidosis in approximately 1997. A December 1997 medical treatment record shows that the Veteran had neurosarcoidosis with T cord involvement resulting in right lower extremity weakness. It is also noted that he had proximal hip flexor weakness. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 08/31/1998, with "#2" in the subject field, pp. 46-47. In a November 1998 letter from Dr. Petra Gurtner, M.D., she wrote, "At this point, I suspect that the weakness in the right leg is due to the lesions which have been diagnosed in the thoracic cord. I think further treatment of the neurosarcoidosis is indicated." See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 06/19/2012, pp. 1-2. An April 2009 private medical record notes that the Veteran had slight restriction of right hip mobility. The examiner wrote he also had mild right lower extremity weakness. See "Medical Treatment Record Government Facility," receipt date 06/17/2013, with "#1" in the subject field, p. 36. An October 2011 x-ray of the right hip showed no fractures or arthropathy. See "Medical Treatment Record Government Facility," receipt date 06/17/2013, with "#1" in the subject field, p. 1. A January 2016 VA examination report shows the examiner diagnosed the Veteran right knee joint osteoarthritis. The Veteran had range of motion of 18 to 108 degrees. He had muscle strength of 3/5 with flexion and 4/5 with extension, and no atrophy in the right lower extremity. See VBMS entry with document type, "C&P Exam," receipt date 01/12/2016, with "DBQ MUSC Knee & lower leg" in the subject field. A March 2020 letter from Kimberly Schat, A.R.N.P.-C.N.P. states that the Veteran's service-connected osteoarthritis of the right knee exacerbated and contributed to his right hip. Ms. Schat stated that within a reasonable degree of medical certainty, it is in her professional medical opinion that the Veteran's right hip condition leading to pain, restricted mobility, and weakness; and right foot degenerative joint disease are more likely than not secondary to his service-connected right knee osteoarthritis. See "Medical Treatment Record Government Facility," receipt date 05/26/2020, with "#2" in the subject field, p. 1. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions: (a.) Did the Veteran have a right hip disability that was caused by the service-connected right knee disability? Please explain upon what facts, medical principles, and/or medical literature the opinion is based. (b.) If the answer to (a.) is negative, did the Veteran have a right hip disability that was aggravated by the service-connected right knee disability? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please explain upon what facts, medical principles, and/or medical literature the opinion is based. (c.) If the examiner finds that right knee disability caused an increase in severity of the Veteran's right hip disability that is not due to the natural progress of the disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the right hip disability prior to aggravation. If the examiner is unable to establish a baseline for the right hip disability prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. Obtain an addendum medical opinion from an appropriate examiner to determine if the right foot disability is caused or aggravated by the service-connected right knee disability. The agency of original jurisdiction is asked to provide the examiner a copy of the below facts. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served in active duty August 1976 to June 1982. The Veteran died in August 2017 due to congestive heart failure due to or as a consequence of hypertensive cardiovascular disease. See VBMS entry with document type, "Death Certificate," receipt date 09/18/2017, item 34. At the time of the Veteran's death, he was service connected for migraines, osteoarthritis of the right knee, tinnitus, and onychomycosis. The Veteran's surviving spouse believes that the service-connected right knee disability caused or aggravated a right foot disability. The records show that the veteran was diagnosed with sarcoidosis in approximately 1997. A December 1997 medical treatment record shows that the Veteran had neurosarcoidosis with T cord involvement resulting in right lower extremity weakness. See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 08/31/1998, with "#2" in the subject field, pp. 46-47. In a November 1998 letter from Dr. Petra Gurtner, M.D., she wrote, "At this point, I suspect that the weakness in the right leg is due to the lesions which have been diagnosed in the thoracic cord. I think further treatment of the neurosarcoidosis is indicated." See VBMS entry with document type, "Medical Treatment Record Government Facility," receipt date 06/19/2012, pp. 1-2. A March 2012 VA examination report shows the examiner diagnosed right hallux valgus, onychomycosis of the right great toenail, and diffuse minimal degenerative joint disease of the right toes. See VBMS entry with document type, "C&P Exam," receipt date 03/29/2012, with "Foot" in the subject field. The March 2012 right foot x-ray found minimal hallux valgus deformity, mild degenerative joint space narrowing at the distal toes, and otherwise unremarkable radiographic series of the right foot without weight-bearing. See VBMS entry with document type, "C&P Exam," receipt date 03/29/2012, with "Right foot x-xay" in the subject field, p. 2. A March 2020 letter from Kimberly Schat, A.R.N.P.-C.N.P. states that the Veteran's service-connected osteoarthritis of the right knee and this condition exacerbated and contributed to his right hip and right foot pain. Ms. Schat stated that within a reasonable degree of medical certainty, it is in her professional medical opinion that the Veteran's right hip condition leading to pain, restricted mobility, and weakness; and right foot degenerative joint disease are more likely than not secondary to his service-connected right knee osteoarthritis. See "Medical Treatment Record Government Facility," receipt date 05/26/2020, with "#2" in the subject field, p. 1. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions: (a.) Was the Veteran's right foot disability of hallux valgus and/or diffuse minimal degenerative joint disease of the right toes caused by the service-connected right knee disability? Please explain upon what facts, medical principles, and/or medical literature the opinion is based. (b.) If the answer to (a.) is negative, was the Veteran's right foot disability of hallux valgus and/or diffuse minimal degenerative joint disease of the right toes is aggravated by the service-connected right knee disability? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please explain upon what facts, medical principles, and/or medical literature the opinion is based. (c.) If the examiner finds that right knee disability caused an increase in severity of the Veteran's right foot disability that is not due to the natural progress of the disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the right foot disability prior to aggravation. If the examiner is unable to establish a baseline for the right foot disability prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Griffin, 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.