Citation Nr: 22012871 Decision Date: 03/07/22 Archive Date: 03/07/22 DOCKET NO. 13-20 876 DATE: March 7, 2022 ORDER Service connection for hepatitis C, including as due to herbicide agent exposure, is denied. Service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD) is denied. Service connection for left lower extremity radiculopathy is granted. Service connection for right lower extremity radiculopathy is granted. A disability rating greater than 50 percent for left ulnar nerve paralysis, including on an extraschedular basis, is denied. Special monthly compensation (SMC) due to the need for aid and attendance of another is denied. Automobile and adaptive equipment, or adaptive equipment only, is denied. REMANDED Service connection for right upper extremity radiculopathy is remanded. Service connection for obstructive sleep apnea, including as secondary to service-connected PTSD, is remanded. Service connection for a heart disability, including as due to herbicide agent exposure, is remanded. Service connection for a skin condition, including as secondary to herbicide agent exposure, is remanded. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that the Veteran's diagnosed hepatitis C began during active service or is otherwise related to an in-service injury or disease. 2. The evidence of record persuasively weighs against finding that the Veteran has had an acquired psychiatric disorder other than PTSD at any time during or approximate to the pendency of the claim. 3. The Veteran's bilateral lower extremity radiculopathy is secondary to his service-connected back disability and has manifested with symptoms since his initial claim. 4. The Veteran's left ulnar nerve disability is rated as 50 percent disabling, which is the maximum schedular rating permitted for paralysis of the ulnar nerve in the nondominant extremity. 5. During the appellate period, the schedular criteria have been adequate to evaluate the Veteran's service-connected left ulnar nerve disability; the evidence establishes that the Veteran experiences numbness, difficulty gripping objects, decreased strength, weakness, and limited movement; these manifestations are adequately contemplated by the currently assigned 50 percent under 38 C.F.R. § 4.124a, Diagnostic Code 8516. 6. The Veteran had not been permanently housebound or in need of regular aid and attendance of another person due to his service-connected disabilities. 7. The Veteran's service-connected disabilities do not result in a loss or loss of use of a hand or foot; permanent impairment of vision of both eyes; a severe burn injury; amyotrophic lateral sclerosis; or ankylosis of a knee or hip. CONCLUSIONS OF LAW 1. The criteria for service connection for hepatitis C are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for an acquired psychiatric disorder other than PTSD are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for left lower extremity radiculopathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for right lower extremity radiculopathy are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for a disability rating in excess of 50 percent for a left ulnar nerve disability, including on an extraschedular basis, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.124a, Diagnostic Code 8516. 6. The criteria for an award of SMC based on aid and attendance have not been met. 38 U.S.C. § 1114(s); 38 C.F.R. §§ 3.102, 3.350(b), 3.352(a). 7. The criteria for establishing eligibility for financial assistance for an automobile or adaptive equipment are not met. 38 U.S.C. §§ 3901, 3902, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.808. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Army from July 1969 to July 1971, including service in the Republic of Vietnam. The instant matter is on appeal from January 2013 and July 2013 rating decisions. In March 2017, the Veteran testified before the undersigned in a Travel Board hearing. A transcript of the proceedings has been associated with the record. The Board remanded these issues in June 2017 for additional evidentiary development. The Regional Office (RO) subsequently granted entitlement to service connection for bilateral lower extremity radiculopathy effective January 25, 2019. As this grant does not cover the entire period on appeal, the matter remains before the Board for adjudication. The Veteran's claims of entitlement to service connection for tinnitus and bilateral hearing loss were granted effective August 13, 2012, the date VA received the Veteran's claim pertaining to those issues. Those grants constitute full grants of benefits sought on appeal, and are therefore no longer on appeal. Service Connection Generally, service connection will be granted for a disability resulting from an injury or disease caused or aggravated by service. 38 U.S.C. §§ 1110. A grant of service connection for a disability requires: (1) a present disability or persistent or recurrent symptoms of a disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the in-service event, injury, or disease. 38 C.F.R. § 3.303; see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Service connection for hepatitis C, including as due to herbicide agent exposure The Veteran contends that he is entitled to service connection for hepatitis C as he believes it was incurred through blood transfusions during 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. The Board concludes that, while the Veteran has a current diagnosis of hepatitis C, and evidence shows that he underwent surgical procedures during service, the evidence of record weighs persuasively against finding that the Veteran's diagnosis of hepatitis C began during service or is otherwise related to an in-service injury, event, or disease. VA treatment records reflect a history of hepatitis C as early as December 2007 with rounds of treatment. Multiple VA examinations have been requested to assess the cause of his hepatitis C. The Board previously deemed the previous causal opinions inadequate in the prior remand; thus, a new opinion was requested to more thoroughly consider the evidence of record. A VA examination was obtained in June 2018 that noted a diagnosis around 2011. The opinion determined that the condition was as likely as not related to service as it had an onset during service as reflected in service treatment records. The Veteran's service treatment records, however, do not reflect such a diagnosis. Instead, service treatment records reflect serious injuries incurred during his combat deployment that required surgical intervention. Following convalescence, this case was considered by a Medical Board, and he was discharged due to these disabilities incurred in combat. The Medical Board performed a thorough evaluation of the Veteran's condition at that time and hepatitis C was not diagnosed, nor was it noted on his separation examination. The opinion did not identify any supportive documents for this finding. Clarification was sought following this opinion, and an addendum opinion was obtained in July 2020. The responsive physician determined that there was no evidence of blood transmissions or hepatitis C during service. While he underwent abdominal surgery, there were no notations regarding a transfusion. The first report of a transfusion occurred in 2016 associated with anemia. The physician stated that the likelihood of the Veteran going decades after service without a diagnosis of hepatitis C was unlikely given the nature of the condition. Further, there was no evidence to support a causal relationship between hepatitis C and herbicide agent or other environmental exposure as hepatitis C is a viral infection of the liver. Therefore, the physician concluded that it was less likely as not that the Veteran's hepatitis C was incurred in or otherwise related to his active duty service. Given the contradictions in the June 2018 medical opinion, the Board affords it no probative weight. The examination noted an onset of hepatitis C in 2011, which contradicts findings of record indicating treatment for the condition as early as 2007. The opinion itself states that service treatment records reflect a diagnosis during active duty, but this is contradicted by the records themselves, which reflect no such diagnosis. As such, this medical opinion lacks credibility as it relies on an inaccurate factual premise, and cannot be afforded any probative weight in the overall analysis. In contrast, the July 2020 addendum opinion considered the totality of the Veteran's claims file, including the prior June 2018 opinion. The physician provided an adequate rationale for the conclusions drawn, and this opinion is supported by the Veteran's medical records both during and after service. Thus, the Board finds that this opinion is credible as it is based on an accurate review of the evidence of record, and thus entitled to significant probative weight overall. While the Veteran believes his hepatitis C is related to an in-service injury, event, or disease, he is not competent (that is, medically qualified) to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Furthermore, the Veteran has not reported a diagnosis during service or continuity of symptoms since service. In the hearing before the undersigned, he reported symptoms approximately 10 to 12 years prior to the hearing, but not during service or immediately thereafter. Consequently, the Board must assign more probative weight to the July 2020 medical opinion denying a causal relationship. In sum, the competent, probative evidence of record reflects that the Veteran's hepatitis C was not incurred during service, including as a consequence of purported blood transfusions during surgery. As the evidence weighs persuasively against finding that the Veteran's hepatitis C is causally related to service, the rule regarding reasonable doubt is not for application, and the claim must be denied. 2. Service connection for an acquired psychiatric disorder other than PTSD The Veteran contends that he is entitled to service connection for an acquired psychiatric disorder other than PTSD. The Veteran is presently in receipt of service connection for PTSD with a 100 percent rating. 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. The Board concludes that the Veteran does not have a current diagnosis of an acquired psychiatric disorder other than PTSD, and he has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran's VA treatment records do not document another mental health diagnosis, and his mental health treatment records only cite to PTSD as a present diagnosis. The Veteran subjectively reports symptoms of depression, but such have been related to his diagnosis of PTSD. Additionally, December 2012 and June 2018 VA examinations only noted a diagnosis of PTSD, but no other mental health conditions. While the Veteran believes that he has another diagnosed mental health condition, he is not competent to render psychiatric diagnoses or differentiate symptoms from his diagnosed PTSD. Thus, his lay statements regarding the existence of another acquired psychiatric disorder cannot be afforded probative weight overall. In contrast, two VA mental health examinations have assessed the Veteran's overall condition and determined that his only diagnosis was PTSD. These opinions were based on evaluation of the Veteran and review of his treatment records. Similarly, his mental health treatment records reflect a diagnosis of PTSD, which was based on review of the Veteran's records and evaluation. Thus, this medical evidence is entitled to significant probative weight overall. In sum, the competent, probative evidence of record fails to establish another mental health diagnosis other than PTSD. As the evidence weighs persuasively against finding a diagnosis of an acquired psychiatric disorder other than PTSD, the rule regarding reasonable doubt is not for application, and the claim must be denied. 3. Service connection for bilateral lower extremity radiculopathy The Board notes that service connection for bilateral lower extremity radiculopathy was established in a September 2021 rating decision effective January 25, 2019, the date of the associated peripheral nerve examination. The Veteran has reported symptoms of bilateral lower extremity radiculopathy throughout the period on appeal. The December 2012 VA examination noted mild paresthesias and/or dysesthesias in the bilateral lower extremities. The Veteran has also reported subjective symptoms of numbness, tingling, and pain in his legs, which were later associated with his diagnosed radiculopathy. The January 2019 VA examination noted occasional radicular symptoms in his bilateral lower extremities related to his service-connected back disability. Subsequent August and September 2021 addenda determined that the lower extremity radiculopathy was a progression of the Veteran's back disability. Accordingly, the Veteran is entitled to service connection for bilateral lower extremity radiculopathy as symptoms manifested in conjunction with his initial claim and continued through the appeal period until formally diagnosed in January 2019. The claim is granted. Increased Ratings Disability ratings are determined by application of a ratings schedule which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, pyramiding, which is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending and, consequently, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disabilities must be reviewed in relation to their entire history. 38 C.F.R. § 4.1. VA must also interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. VA is also required to evaluate functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Functional loss may be due to pain if supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Functional impairment may be due to pain, including during flare-ups, or from repetitive use. Mitchell v. Shinseki, 25 Vet. App. 32, 43-44 (2011). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno, 6 Vet. App. at 465. Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 C.F.R. § 3.159; see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. 4. The claim of entitlement to a rating in excess of 50 percent for left ulnar nerve paralysis, including on an extraschedular basis The Veteran contends that he is entitled to a higher rating for his left ulnar nerve paralysis as the nerve is completely paralyzed. The Veteran is right hand dominant, thus the Board must consider this rating under provisions for the nondominant, or minor, extremity. Paralysis of the ulnar nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8516. Under these criteria, complete paralysis of the nerve is entitled to a 50 percent rating for the minor extremity, and manifests with symptoms of the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of wrist weakened; pain with trophic disturbances. The Veteran is presently at the schedular maximum for this disability and has been throughout the appellate period. The issue of consideration of an extraschedular rating was raised by the Veteran's representative in the hearing before the undersigned. Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran's disability picture. If the schedular evaluation does not contemplate the level of disability and symptoms shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant's symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. Neither the Veteran nor his representative have identified symptoms outside of those contemplated by the rating schedule. They have endorsed symptoms of numbness, difficulty gripping, and difficulty with movements. VA examinations of record have noted symptoms of weakness, some muscle wasting, numbness, and some contracture deformity of the fourth and fifth fingers. In regard to the first Thun element, comparison of the Veteran's symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. The Board acknowledges the Veteran's assertion that his symptoms are not contemplated under the schedular criteria. However, given the broad nature of § 4.120, finding symptoms not contemplated by 'impairment of motor, sensory or mental function' language presents quite a challenge." Spellers v. Wilkie, 30 Vet. App. 211, 218 (2018). The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. The Veteran's representative described his contention in support of an extraschedular rating as more of a disagreement with how the rating criteria are presently assessed. He believes that a total paralysis of a nerve should warrant a 100 percent rating instead of a 50 percent rating. The representative described the Veteran's arm as "dead" but this complete loss of use is not supported by the record. Instead, his symptoms are adequately contemplated by the rating criteria for Diagnostic Code 8516 and the maximum schedular rating. Therefore, the Board concludes that the Veteran's left ulnar nerve disability is adequately contemplated by the rating criteria and does not present marked interference with employment or frequent periods of hospitalization; thus, remand for consideration of an extraschedular rating is not warranted. The evidence weighs persuasively against a rating in excess of 50 percent for the Veteran's left ulnar nerve disability, including on an extraschedular basis. Accordingly, the rule regarding reasonable doubt is not for application, and the claim must be denied. 5. The claim of entitlement to SMC due to the need for aid and attendance of another The Veteran seeks entitlement to SMC based on the need for the regular aid and attendance of another person. He is presently in receipt of SMC due to one service-connected disability rated at 100 percent and a second at 60 percent or more. Generally, with respect to claims of entitlement to SMC based on the need for the regular aid and attendance of another person, such claims will be granted when a veteran, due to a service-connected disability, has the anatomical loss or loss of use of both feet or one hand and one foot, or is blind in both eyes, or is permanently bedridden or so helpless as to be in need of regular aid and attendance. See 38 U.S.C.§ 1114(l); 38 C.F.R. § 3.350(b). Determinations as to the need for aid and attendance must be based on actual requirements of personal assistance from others. In making such determinations, consideration is given to the following: inability of a veteran to dress or undress himself/herself or to keep himself/herself ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which, by reason of the particular disability, cannot be done without aid; inability of a veteran to feed himself/herself through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a veteran from the hazards or dangers inherent in his/her daily environment. Being bedridden will be a proper basis for the determination, and is defined as that condition which, through its essential character, actually requires that the veteran remain in bed. It is not required that all of the disabling conditions listed above be found to exist before a favorable rating may be made. The particular personal functions that a veteran is unable to perform should be considered in connection with his/her condition as a whole. It is only necessary that the evidence establish that a veteran is so helpless as to need regular aid and attendance, not that there be a constant need. 38 C.F.R. § 3.352(a). The Veteran was in receipt of service connection for the following disabilities: PTSD (100 percent); complete paralysis of the left ulnar nerve (50 percent); left humerus fracture (20 percent); lumbar spine disability (20 percent); right foot gunshot wound residuals (20 percent); left elbow skin graft (20 percent); residuals of coccyx removal (10 percent); muscle injury (10 percent); peritoneum adhesions (10 percent); left buttock scar (10 percent); tinnitus (10 percent); left lower extremity radiculopathy (10 percent); right lower extremity radiculopathy (10 percent); and bilateral hearing loss (noncompensable). For the following reasons, the Board finds that entitlement to SMC based on the need for aid and attendance is not warranted. In this case, the evidence of record does not reflect that the Veteran had the anatomical loss or loss of both feet or one hand and one foot or is blind in both eyes. See 38 U.S.C. § 1114(l); 38 C.F.R. § 3.350(b). The remaining question is whether the Veteran was so helpless as to be in need of regular attendance due to his service-connected disabilities. The evidence of record does not indicate that the Veteran needed regular aid and attendance due to service-connected disabilities throughout the appeal period. The December 2012 aid and attendance examination determined that the Veteran could perform his daily self-care functions. He was able to dress and feed himself, as well as use the bathroom without assistance. He could fix his own meals, but his wife did the cooking. The Veteran drove around town if needed. There was no imbalance that affected his ability to ambulate, and his gait was normal. VA treatment records similarly reflect independence in his activities of daily living. By way of example, he was noted to be independent in his activities of daily living in April 2019 while undergoing mental health treatment. He experienced some dizziness and anemia associated with a kidney condition, which is not presently service connected. In sum, the evidence of record does not reflect that the Veteran is so helpless as to be in need of regular aid and attendance due to his service-connected disabilities. While his service-connected disabilities have varying levels of functional impairment, they were not shown to be so severe as to require the aid and attendance of another. The Veteran has been found to be capable of self-care functions, including dressing and toileting independently, and he remains independent in his other activities of daily living. For the foregoing reasons, the evidence weighs persuasively against the claim for SMC based on aid and attendance. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. Automotive Adaptive Benefits 6. The claim of entitlement to automobile and adaptive equipment, or adaptive equipment only The Veteran contends that he is entitled to financial assistance for an automobile and adaptive equipment or for adaptive equipment only because he has paralysis of the left ulnar nerve and other physical disabilities. Financial assistance may be provided to an "eligible person" in acquiring an automobile or other conveyance and adaptive equipment, or adaptive equipment only. 38 U.S.C. § 3902(a)(b). Eligibility for assistance to purchase a vehicle and adaptive equipment is warranted where one of the following exists as the result of injury or disease incurred or aggravated during active service: (1) loss or permanent loss of use of one or both feet; (2) loss or permanent loss of use of one or both hands; (3) permanent impairment of vision of both eyes, meaning central visual acuity of 20/200 or less in the better eye, with corrective glasses, or central visual acuity of more than 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field subtends an angular distance no greater than 20 degrees in the better eye; (4) severe burn injury precluding effective operation of an automobile; (5) amyotrophic lateral sclerosis; or, (6) for adaptive equipment only, ankylosis of one or both knees or one or both hips. 38 U.S.C. § 3901; 38 C.F.R. § 3.808. The Veteran was in receipt of service connection for the following disabilities: PTSD (100 percent), complete paralysis of the left ulnar nerve (50 percent); left humerus fracture (20 percent); lumbar spine disability (20 percent); right foot gunshot wound residuals (20 percent); left elbow skin graft (20 percent); residuals of coccyx removal (10 percent); muscle injury (10 percent); peritoneum adhesions (10 percent); left buttock scar (10 percent); tinnitus (10 percent); left lower extremity radiculopathy (10 percent); right lower extremity radiculopathy (10 percent); and bilateral hearing loss (noncompensable). The Veteran has not specifically endorsed difficulty driving. He reported wanting a ramp to help him get into his car in the hearing before the undersigned, but then later described seeking a ramp going into his home. While he has described difficulty grasping with his left hand, he has not related this specifically to his automobile or driving capabilities. The December 2012 aid and attendance examination noted that he drove himself around town without issue. The term "loss of use of a hand or foot" is not defined under 38 C.F.R. § 3.808, but the definition under 38 C.F.R. § 3.350 (a)(2)(i), pertaining to SMC, is generally applied. See Hoggard v. Shinseki, No. 08-2188, 2009 U.S. App. Vet. Claims LEXIS 2126 (Dec. 4, 2009) (affirming the Board's use of "loss of use of a foot" under § 3.350 (a)(2)(i) to deny auto/adaptive benefits under 38 U.S.C. § 3901(2) and 38 C.F.R. § 3.808"). Under 38 C.F.R. § 3.350 (a)(2)(i), "loss of use" is defined as existing when "no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow or knee with the use of a suitable prosthetic appliance." See also 38 C.F.R. § 4.63. The probative medical evidence persuasively weighs against the Veteran having loss of use of his hands or feet due to a service-connected disorder. Initially, the Board notes that he does not have a diagnosis of ankylosis of the knee or hip, nor its functional equivalent. Further, he does not have a service-connected vision disability. While the Veteran's ulnar nerve paralysis is complete, VA examinations have not indicated that he has permanently lost use of the hand as a result. By way of example, in the January 2019 examination, the examiner determined that the condition is not so severe as to render the hand with no effective function, and the Veteran would not be equally well served by an amputation with a prosthesis. While the Veteran is service connected for lower extremity disabilities as well, the evidence of record does not reflect that he has lost use of either of his feet as a result of these disabilities. VA treatment records reflect normal gait with muscle tone and strength within normal limits. The only indication of difficulty driving in his VA treatment records is associated with hematology treatments for a nonservice-connected condition, and other outpatient VA procedures that required sedation. While the Veteran may have decreased strength and coordination in his left arm which may make walking long driving for long periods challenging, the evidence shows that the Veteran is able to independently ambulate with a normal gait and has not at any time had loss of use of a foot or hand, such that he is unable to avail himself of its use. The Board assigns great weight to the medical evidence and notes that it is the Board's responsibility, not the evaluating medical professionals, to determine whether "loss of use" exists. Tucker v. West, 11 Vet. App. 369 (1998). The evidence of record persuasively weighs against finding that the Veteran's service-connected ulnar nerve disability has resulted in a loss of use. The Board has considered the lay statements of the Veteran regarding his problems with navigating into and out of his car, as well as weakness and difficulty grasping with his left hand. The Board does not doubt those assertions, as the Veteran is competent (that is, medically qualified) to report these readily observable symptoms. See Jandreau, 492 F.3d at 1377. Those statements are credible and consistent with the medical evidence of record. These statements, however, are insufficient to establish loss of use of his hand, and they do not outweigh the medical evidence that demonstrates that the claimant does not meet any of the required criteria under 38 C.F.R. § 3.808. Although the Veteran is not eligible for a grant for automobile adaptations under 38 C.F.R. § 3.808, the Board recommends that he consult with his VA treatment provider about whether he is eligible for specific vehicle modifications from the VA Prosthetic and Sensory Aids Service. In sum, the competent and probative medical evidence of record persuasively weighs against finding that the Veteran's service-connected disabilities meet any of the criteria under 38 C.F.R. § 3.808, the claim for an automobile and adaptive equipment, or adaptive equipment only, is denied. REASONS FOR REMAND 1. Service connection for right upper extremity radiculopathy The Board sincerely regrets the additional delay, but remand is necessary to obtain an adequate opinion on the Veteran's claimed right upper extremity radiculopathy. A December 2012 VA examination noted mild paresthesias and/or dysesthesias in the right upper extremity. The Veteran has reported subjective symptoms of numbness and tingling in the extremity. The January 2019 VA examination noted mild numbness in the right upper extremity with absent reflexes in the biceps, triceps, and brachioradialis. Unfortunately, an opinion was rendered on this issue that did not reflect an understanding of the Veteran's present service-connected disabilities and their progression. While an addendum was obtained in September 2021, the opinion only addressed lower extremity radiculopathy. Thus, remand is necessary to address the findings of radicular symptoms in the right upper extremity and their cause. 2. Service connection for obstructive sleep apnea, including as secondary to service-connected PTSD, is remanded. Remand is additionally necessary to obtain an adequate opinion regarding the cause of the Veteran's obstructive sleep apnea. While an addendum opinion was obtained in July 2020, the examiner did not address the issue of whether the Veteran's obesity constituted an intermediary step between his service-connected disabilities and his diagnosed obstructive sleep apnea. The Veteran's treatment records note that he is obese, and journal articles provided by the Veteran's representative indicate a correlation between acquired psychiatric disorders and obesity, due at least in part to medications taken to treat those mental health conditions, as well as overall lower levels of activity. Accordingly, remand is necessary to obtain an adequate causal opinion on this issue. 3. Service connection for a heart disability, including as due to herbicide agent exposure, is remanded. Remand is also necessary to obtain an adequate opinion on the Veteran's claimed heart disability. The Veteran's VA treatment records reflect a past medical history of heart disease and a prescription for medication taken regularly for his heart. Records also reflect heart palpitations, a heart murmur, and a concern for congestive heart failure. By way of example, in July 2015, the Veteran sought treatment for dyspnea and there was a documented concern for congestive heart failure. The Veteran has reported experiencing heart palpitations and feelings of tiredness associated with his claimed cardiac condition. In January 2018, an echocardiogram showed a systolic murmur in the aortic area, and there was a slight thickening of the aortic valve without a report of stenosis. In contrast, the January 2019 VA examination reports that the Veteran does not have a diagnosed cardiac condition, nor does he have complaints of cardiac symptoms; however, the same examination report checks the box for the Veteran having a diagnosis of a heart condition. The findings of the January 2019 VA examination conflict with those of the Veteran's VA treatment records. Accordingly, remand is necessary for an addendum to clarify the precise nature of the Veteran's claimed heart condition and resolve these discrepancies. 4. Service connection for a skin condition, including as secondary to herbicide agent exposure, is remanded. Remand is also necessary to obtain a medical opinion addressing the cause of the Veteran's claimed skin condition. The Veteran has been diagnosed with onychomycosis and tinea pedis. He has reported symptoms of tinea pedis since his service in Vietnam. A medical opinion was not requested in conjunction with the December 2012 VA skin examination. While the previous Board remand requested a new VA examination, the Veteran declined to reschedule this examination as he did not want to travel for another examination. No opinion was obtained based on the evidence of record. Accordingly, remand is required to obtain a nexus opinion on the Veteran's claimed skin condition based upon a review of the medical and lay evidence already associated with the claims file. The matters are REMANDED for the following action: 1. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). All attempts to contact the Veteran should be documented in the record. 2. Once the aforementioned evidentiary development is complete, obtain an addendum opinion to assess the nature and cause of the Veteran's claimed right upper extremity radiculopathy. The examiner must review the entire claims file, including a copy of this remand. A new examination may be scheduled if deemed necessary. If the Veteran declines a new examination or fails to report, a medical opinion should still be obtained. The examiner must consider the Veteran's lay reports of observable symptoms. After a thorough review of the record is complete, the examiner must respond to the following: (a.) Does the Veteran have a present diagnosis of right upper extremity radiculopathy or other nerve impairment? If not, please address the December 2012 and January 2019 findings of right upper extremity symptoms. (b.) If so, opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's right upper extremity radiculopathy had its onset during active duty service, is related to an incident of service, or began within one year after discharge from active service, including exposure to herbicide agents. (c.) If not directly related to service, is it at least as likely as not that the radiculopathy was caused by his service-connected disabilities? (d.) Is it at least as likely as not that the radiculopathy was aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless of permanence) by his service-connected disabilities? The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 3. Once the aforementioned evidentiary development is complete, obtain an addendum opinion regarding the cause of the Veteran's obstructive sleep apnea. A new examination may be ordered if deemed necessary. If the Veteran declines a new examination or fails to report, a medical opinion should still be obtained. The examiner must review the entire claims file, including a copy of this remand. The examiner must consider the Veteran's lay reports of observable symptoms. After a thorough review of the record is complete, the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran's obstructive sleep apnea had its onset during his active duty service or is otherwise related service? (b.) If not, is it at least as likely as not (50 percent or greater probability) that the Veteran's obstructive sleep apnea was caused by his service-connected disabilities, including medications taken for the conditions? (c.) If not, is it at least as likely as not (50 percent or greater probability) that the Veteran's obstructive sleep apnea was aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless of permanence) by his service-connected disabilities, including medications taken for the conditions? (d.) Did the Veteran's service-connected disabilities, including PTSD, cause him to become obese? (e.) If so, is the Veteran's obesity a substantial factor in causing or aggravating his sleep apnea? (f.) Would the Veteran's sleep apnea not have occurred but for the obesity caused or aggravated by his service-connected disabilities, including PTSD? The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 4. Once the aforementioned evidentiary development is complete, obtain an addendum opinion to assess the nature and cause of his claimed heart condition. The examiner must review the entire claims file, including a copy of this remand. A new examination may be scheduled if deemed necessary. If the Veteran declines a new examination or fails to report, a medical opinion should still be obtained. The examiner must consider the Veteran's lay reports of observable symptoms. After a thorough review of the record is complete, the examiner must respond to the following: (a.) List any and all cardiac conditions with which the Veteran is presently diagnosed. Please specifically discuss the Veteran's heart murmur, reports of tiredness associated with palpitations, and other cardiac symptoms noted in echocardiograms from 2008 and 2018. (b.) For each identified diagnosis, opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's identified diagnosis had its onset during active duty service, is related to an incident of service, or began within one year after discharge from active service, including as due to exposure to herbicide agents. To note, even if a claimed cardiac condition is not presumptively related to herbicide agent exposure, this presumption does not bar the finding of a direct causal relationship. The examiner may not state that it is less likely as not that an identified condition is related to active duty service because it is not a presumptive condition of herbicide agent exposure. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 5. Once the aforementioned evidentiary development is complete, obtain an addendum opinion to assess the nature and cause of the Veteran's claimed skin condition. The examiner must review the entire claims file, including a copy of this remand. The examiner must consider the Veteran's lay reports of observable symptoms. After a thorough review of the record is complete, the examiner must respond to the following: (a.) List any and all skin conditions with which the Veteran is presently diagnosed. Please specifically address tinea pedis and onychomycosis. (b.) For each identified diagnosis, opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's identified diagnosis had its onset during active duty service, is related to an incident of service, or began within one year after discharge from active service, including as due to exposure to herbicide agents. To note, even if a claimed skin condition is not presumptively related to herbicide agent exposure, this presumption does not bar the finding of a direct causal relationship. The examiner may not state that it is less likely as not that an identified condition is related to active duty service because it is not a presumptive condition of herbicide agent exposure. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. 6. Following completion of the foregoing, the AOJ should review the record and readjudicate the claims on appeal. If any remain denied, the AOJ should issue an appropriate supplemental SOC, afford the Veteran and the representative of record an opportunity to respond, and return the case to the Board. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Fisher, 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.