Citation Nr: 22014777 Decision Date: 03/15/22 Archive Date: 03/15/22 DOCKET NO. 18-21 471 DATE: March 15, 2022 ORDER New and material evidence having been received, the claim for service connection for residuals of rocket fragment to the left side of his head is reopened. To that extent, the appeal is granted. Entitlement to an effective date earlier than August 13, 2012, for the grant of service connection for tinnitus is denied. Entitlement to an initial rating in excess of 10 percent for tinnitus is denied. Entitlement to service connection for coronary artery disease (CAD) is granted. REMANDED Entitlement to service connection for hypertension (HTN) is remanded. Entitlement to service connection for residuals of rocket fragment to the left side of his head is remanded. Entitlement to service connection for chronic headaches is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for lumbar spine arthritis is remanded. Entitlement to service connection for bilateral knee arthritis is remanded. Entitlement to service connection for bilateral elbow arthritis is remanded. Entitlement to service connection for bilateral hand arthritis is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability is remanded. FINDINGS OF FACT 1. The evidence received since the January 2004 denial relates to an unestablished fact necessary to substantiate the claim for service connection for residuals of rocket fragment to the left side of his head, and raises a reasonable possibility of substantiating the claim. 2. The VA received a claim for service connection for tinnitus on August 13, 2012. 3. The Veteran's service-connected bilateral tinnitus is assigned a 10 percent rating, the maximum rating authorized under Diagnostic Code 6260. 4. The Veteran's CAD is presumed to be related to his exposure to herbicide agents while serving in Vietnam. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the previously denied claim for service connection for residuals of rocket fragment to the left side of his head. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156(a). 2. The criteria for an effective date earlier than August 13, 2012, for the grant of service connection for tinnitus have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 3. The criteria to establish an initial disability rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.87, Diagnostic Code 6260. 4. The criteria for service connection for CAD due to herbicide exposure have been met. 38 U.S.C. §§ 1110, 1116, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active-duty service from September 1968 to September 1970, to include service in the Republic of Vietnam from April 1969 to April 1970. This matter comes to the Board of Veterans' Appeals (Board) from an October 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran recently testified at a video conference hearing before a Veterans Law Judge (VLJ) of the Board in December 2021. The Board further notes that at the time of the hearing the Veteran raised the issue of entitlement to TDIU and as the Veteran had a claim for increased rating, the Board agreed to recognize and included claim for TDIU. New and material evidence Generally, a final decision issued by the agency of original jurisdiction may not thereafter be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105(c), (d). However, if 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. 38 U.S.C. § 5108. In a claim to reopen, VA must notify a claimant of the information and evidence necessary to reopen the claim and establish entitlement to the underlying claim for the benefit being sought. Kent v. Nicholson, 20 Vet. App. 1 (2006). To satisfy that requirement, VA is required to look at the bases for the denial in the prior decision and provide the claimant with a notice letter that describes what information and evidence would be necessary to substantiate those elements required to establish service connection that were found insufficient in the previous denial. "New evidence" is evidence that has not previously been reviewed by VA adjudicators. "Material evidence" is existing evidence, that, by itself or when 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 final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether evidence is new and material, the credibility of the newly presented evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510 (1992). The Board must review all of the evidence submitted since the last final disallowance of the claim on any basis in order to determine whether the claim may be reopened. Hickson v. West, 12 Vet. App. 247 (1999). The phrase "raise a reasonable possibility of substantiating the claim" does not create a third element for new and material evidence; rather, it provides guidance in determining whether submitted evidence meets the new and material requirements. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). VA has a duty to assist a claimant in the development of a claim. That duty includes assisting in obtaining service medical records and pertinent treatment records and providing an examination or obtaining an opinion when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Whether new and material evidence has been received to reopen a claim for service connection for residuals of rocket fragment to the left side of his head The Veteran claims that in-service events caused his residuals of rocket fragment to the left side of his head. The claim for service connection for residuals of rocket fragment to the left side of his head was originally denied in a January 2004 rating decision. The claim was denied because his service treatment records did not show treatment for rocket fragments, an in-service injury, and there was no medical evidence showing a current disability related to the claimed residuals of a rocket fragments to the left side of the Veteran's head. There is also no indication that new and material evidence was received within the one year following that decision that would have been pertinent to the issue on appeal. 38 C.F.R. § 3.156(b). Thus, the decision became final. As a new claim was received, the claim was readjudicated in October 2015. The pertinent evidence received since the January 2004 denial include sworn testimony from the Veteran explaining his claimed in-service rocket fragment injury to the left side of his head. The Veteran also noted his belief that this injury likely led to his current service-connected tinnitus and his headache disorder. Presuming the credibility of the evidence, the record now indicates that the Veteran may have residuals of rocket fragment to the left side of his head, that may be related to service. The evidence is new, not cumulative, and relates to an unestablished fact necessary to substantiate the claim. Thus, as new and material evidence has been received, the claim for service connection for residuals of rocket fragment to the left side of his head is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Effective Date Generally, the effective date for an award of service connection and disability compensation is the day following separation from active service or the date entitlement arose if the claim is received within one year after separation from service; otherwise, for an award based on an original claim, a claim reopened after a final allowance, or a claim for an increase, the effective date will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. An application for VA compensation must generally be a specific claim in the form prescribed by the Secretary, i.e., VA Form 21-526. 38 U.S.C. § 5101(a); 38 C.F.R. § 3.151(a). However, any communication received from the claimant (or specified individuals) that indicates an intent to apply for one or more VA benefits, and identifies the benefit sought, may be considered an informal claim. 38 C.F.R. § 3.155(a). The words "claim" and "application" are defined as a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p). When there is an approximate balance of positive and negative evidence regarding any matter material to the resolution of a claim, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107. 2. Entitlement to an effective date earlier than August 13, 2012, for the grant of service connection for tinnitus The Veteran contends that the effective date for the grant of service connection for tinnitus should be earlier than August 13, 2012. Based on a thorough review of the record, the Board finds that the most persuasive evidence is against the Veteran's claims for an effective date earlier than August 13, 2012, for the grant of service connection for tinnitus. The Veteran did not file a formal or informal claim for service connection for tinnitus before August 13, 2012. The August 13, 2012, claim ultimately led to the October 2015 rating decision that granted service connection for tinnitus with an effective date of August 13, 2012. Applying the pertinent VA regulation (38 C.F.R. § 3.400) to the facts, it is clear that an effective date earlier than August 13, 2012, is not warranted for the grant of service connection for tinnitus. The Veteran has also not offered any authority for the proposition that an earlier effective date is warranted. As the most persuasive evidence is against the Veteran's claim for an effective date prior to August 13, 2012, for the grant of service connection for tinnitus, the benefit of the doubt doctrine is not warranted. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Increased Rating A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In considering the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). 3. Entitlement to an initial rating in excess of 10 percent for tinnitus The Veteran and his attorney assert that the Veteran is entitled to a rating in excess of 10 percent for his tinnitus, to include a separate compensable evaluation for each ear. The Veteran's service-connected tinnitus is currently rated under 38 C.F.R. § 4.87, Diagnostic Code 6260. Under Diagnostic Code 6260, only a single 10 percent rating is warranted for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. This is the maximum schedular rating assignable for tinnitus. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2); Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). Although the Veteran argues that he is entitled to a rating in excess of 10 percent for tinnitus, Diagnostic Code 6260 precludes an evaluation in excess of a single 10 percent schedular rating for tinnitus. As there is no legal basis upon which to award an increase, to include a separate schedular rating for tinnitus in each ear, the claim for an increased rating must be denied based on a lack of entitlement under the law. Sabonis v. Brown, 6 Vet. App. 426 (1994). The Board further notes that to the extent the Veteran is also seeking service connection for headaches in part as secondary to his tinnitus, this will be addressed as part of his claim for service connection for headaches, and as there is no other symptom described by the Veteran that is not already contemplated by the 10 percent rating, there is no basis to consider extraschedular referral as there is no reasonable possibility that there is any basis for such a claim. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b), Walker v. Shinseki, 708 F.3d 1331. (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge from service when all of the evidence, including lay evidence, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). In order to establish service connection for a claimed disability, the following three elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Hickson v. West, 12 Vet. App. 246 (1999). The requirement of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). Service connection may also be granted for certain specified diseases on a presumptive basis if a veteran was exposed to Agent Orange during active service. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(b), 3.309(e). A veteran is presumed exposed to Agent Orange if he or she had active military, naval, or air service, in the Republic of Vietnam from January 9, 1962, through May 7, 1975, "unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service." 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The list of diseases associated with exposure to these herbicide agents is as follows: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes), Hodgkin's disease, ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and also stable, unstable and Prinzmetal's angina), all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, early-onset peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The diseases listed at 38 C.F.R. § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne, porphyria cutanea tarda, and acute and subacute peripheral neuropathy shall have become manifest to a degree of 10 percent or more within a year after the last date on which the veteran was exposed to an herbicide agent during active military, naval, or air service. 38 C.F.R. § 3.307(a)(6)(ii). Lastly, the availability of presumptive service connection for a disability based on exposure to herbicides, however, does not preclude a veteran from establishing service connection with proof of direct causation. Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In evaluating the evidence in an appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold same and, in doing so, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to the evidence. Jandreau v. Nicholson, 492 F.3d 1372 (2007). Competent lay evidence is any kind of evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the more persuasive evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 4. Entitlement to service connection for coronary artery disease (CAD) The Veteran and his attorney claim that his diagnosed CAD is due to his active-duty service. A condition precedent for establishing service connection is the presence of a current disability. The Board notes that the Veteran has not been afforded a VA examination for his CAD. The Board also notes that the Veteran's treatment records confirm a diagnosis of CAD. Therefore, the Board finds that the first element for establishing service connection has been met. Because ischemic heart disease is one of the diseases presumed to be due to in-service exposure to herbicides, the Veteran need only establish that he either directly was exposed to herbicides or is presumed to have been exposed to herbicides to be entitled to service connection. 38 C.F.R. § 3.307(a)(6)(iii), 38 C.F.R. § 3.309(e). In that regard, the Board notes that the Veteran was part of the TET offensive, and his duties included having to go out on helicopters to retrieve deceased soldiers. Additionally, according to his DD214, the Veteran was awarded the Vietnam Service and Vietnam Campaign Medals, and was noted as serving in the Republic of Vietnam from April 1969 to April 1970. Accordingly, the Board finds the Veteran is presumed to have been exposed to herbicides. Therefore, herbicide exposure is conceded and the second element for establishing service connection has been met. As outlined above, the Veteran is presumed exposed to herbicide agents, and therefore, the Veteran is entitled to presumptive service connection for CAD. As the Veteran's ischemic heart disease manifested to a compensable degree, and VA has found that there is a link between herbicide exposure and the Veteran's ischemic heart diseases, service connection for CAD as due to herbicide exposure is warranted. REASONS FOR REMAND 1. Entitlement to service connection for hypertension (HTN) is remanded. The Veteran and his attorney contend that his diagnosed HTN are due to his active-duty service. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. A condition precedent for establishing service connection is the presence of a current disability. The Board notes that the Veteran has not been afforded a VA examination for his HTN; however, the Board also notes that the Veteran's treatment records confirm a diagnosis of HTN. In light of the Veteran's service in Vietnam and presumed Agent Orange exposure, and his contentions regarding his disabilities, the Board finds that remand for a VA examination and medical opinion is necessary. See Healey v. McDonough, 33 Vet. App. 312 (2021). Additionally, there is no opinion of record addressing whether the Veteran's HTN was caused by his exposure to herbicide agents. It is also noted that the National Academies of Sciences, Engineering and Medicine (NAS) issued an update in 2018. In "The Veterans and Agent Orange: Update 11 (2018)," NAS upgraded HTN from its previous classification in the category of "limited or suggestive" evidence of an association to Agent Orange to the category of "sufficient" evidence of an association. According to NAS, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between HTN and herbicide exposure. In light of the foregoing, the Board finds that an opinion addressing whether there is a relationship between the Veteran's HTN and exposure to herbicide agents should be obtained. Id. 2. Entitlement to service connection for residuals of rocket fragment to the left side of his head is remanded. 3. Entitlement to service connection for chronic headaches is remanded. The Veteran and his attorney assert that his claimed residuals of rocket fragment to the left side of his head and his diagnosed chronic headaches originated due to an injury suffered during his active-duty service. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. During the December 2021 Board hearing, the Veteran explained the circumstances regarding his claimed in-service rocket fragment injury to the left side of his head. The Veteran also noted his belief that this injury likely led to his current service-connected tinnitus and his headache disorder. As the Veteran is competent to report that which he perceives through his symptoms, the Board finds this sworn statement to be competent and credible to report what he witnessed first-hand during his active-duty service. Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran was not afforded a VA examination. According to private treatment records, the Veteran has been diagnosed with chronic headaches. According to an August 2019 letter from his physician, his post-operative diagnosis remained unchanged, but the physician noted that he had not treated the Veteran since August 2012. As the Veteran's lay statements and treatment records reflect that the Veteran has disabilities that could be related to active-duty service, the Board finds that a medical examination with an opinion is necessary to decide the claims. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 70 (2006). Specifically, a remand is required to afford the Veteran a VA examination so as to determine the nature, etiology, and severity for residuals of rocket fragment to the left side of his head and chronic headaches. 4. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran and his attorney contend that his claimed bilateral hearing loss originated due to exposure to acoustic trauma during his active-duty service. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. The Veteran was afforded a VA examination in September 2015, at which time the Veteran did not meet the criteria established under 38 C.F.R. § 3.385. However, the Board notes that the examination revealed abnormal bilateral ipsilateral acoustic reflexes and contralateral acoustic reflexes. Additionally, sensorineural hearing loss was noted in the bilateral ears. During the December 2021 Board hearing, the Veteran provided sworn testimony noting that his claimed hearing loss did not preexist his active-duty service. The Veteran also stated that he was exposed to explosions during his service and was provided with inadequate hearing protection. The Veteran also stated that he has had issues with hearing loss since he left the service. The Board notes that the examination confirmed that the Veteran had some sensorineural hearing loss in the bilateral ears, which did not meet the criteria established for VA purposes. However, the Veteran has credibly reported experiencing bilateral ear hearing loss, which may have worsened since his last VA examination. Therefore, the Board finds that another VA examination is warranted to determine whether the Veteran's claimed hearing loss has reached a severity that meets the criteria established under 38 C.F.R. § 3.385. 5. Entitlement to service connection for lumbar spine arthritis is remanded. 6. Entitlement to service connection for bilateral knee arthritis is remanded. 7. Entitlement to service connection for bilateral elbow arthritis is remanded. 8. Entitlement to service connection for bilateral hand arthritis is remanded. The Veteran and his attorney affirm that his arthritis in the lumbar spine, bilateral knees, bilateral elbows, and bilateral hands originated during his active-duty service. Although further delay is regrettable, the Board finds that additional development is necessary prior to appellate review. At the December 2021 Board hearing, the Veteran provided sworn testimony and testified that his back, bilateral knee, bilateral elbow, and bilateral hand pain began during his service. As the Veteran is competent to report that which he perceives through his symptoms, the Board finds this sworn statement to be competent and credible to report what he witnessed first-hand during his active-duty service. Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran was not afforded VA examinations for these disabilities. According to private treatment records, the Veteran has been diagnosed with arthritis in the lumbar spine, bilateral knees, bilateral elbows, and bilateral hands. As the Veteran's lay statements, and treatment records indicate that the Veteran has disabilities that could be related to active-duty service, the Board finds that medical examinations with opinions are necessary to decide the claims. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 70 (2006). Specifically, a remand is required to afford the Veteran a VA examination so as to determine the nature, etiology, and severity for arthritis in the lumbar spine, bilateral knees, bilateral elbows, and bilateral hands. 9. Entitlement to TDIU is remanded. As the grant of service connection for CAD and remand of additional issues may impact the remaining issue of entitlement to TDIU, the Board will defer the adjudication of this issue pending the assignment of a rating for the Veteran's CAD and the completion of the development requested with respect to the remanded claims. The matters are REMANDED for the following action: 1. Obtain any outstanding VA and private treatment records and associate them with the Veteran's claims file. 2. After the above-noted development has been completed and all records associated with the claims file, the Veteran must be afforded a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran's HTN. Any and all studies, tests, and evaluations that are deemed necessary by the VA examiner should be performed. The claims folder, including a copy of this remand, the Veteran's lay statements, the Veteran's Board hearing testimony, and medical records, should be made available and be reviewed by the examiner. Following a complete review of the record, the examiner is asked to: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's HTN originated during, or is etiologically related to, the Veteran's active-duty service, to include as due to exposure to herbicides. (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's HTN originated due to, or was aggravated by, a service-connected disability, to specifically include his CAD. (c) The examiner is asked to specifically address the Veteran's lay statements and December 2021 Board hearing testimony regarding the onset and symptoms associated with the diagnosed HTN. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 3. After the above-noted development has been completed and all records associated with the claims file, the Veteran must be afforded a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran's claimed residuals of rocket fragment injury to the left side of his head. Any and all studies, tests, and evaluations that are deemed necessary by the VA examiner should be performed. The claims folder, including a copy of this remand, the Veteran's lay statements, the Veteran's Board hearing testimony, and medical records, should be made available and be reviewed by the examiner. Following a complete review of the record, the examiner is asked to: (a) Confirm a current diagnosis as to the Veteran's claimed residuals of rocket fragment injury to the left side of his head, to include residuals of traumatic brain injury. (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's claimed residuals of rocket fragment injury to the left side of his head originated during, or is etiologically related to, the Veteran's active-duty service. (c) The examiner is asked to specifically address the Veteran's lay statements and December 2021 Board hearing testimony regarding the onset and symptoms associated with the claimed residuals of rocket fragment injury to the left side of his head. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. After the above-noted development has been completed and all records associated with the claims file, the Veteran must be afforded a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran's diagnosed chronic headaches. Any and all studies, tests, and evaluations that are deemed necessary by the VA examiner should be performed. The claims folder, including a copy of this remand, the Veteran's lay statements, the Veteran's Board hearing testimony, and medical records, should be made available and be reviewed by the examiner. Following a complete review of the record, the examiner is asked to: (a) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed chronic headaches originated during, or is etiologically related to, the Veteran's active-duty service or service-connected disability. (b) The examiner is asked to specifically address the Veteran's lay statements and December 2021 Board hearing testimony regarding the onset and symptoms associated with the diagnosed chronic headaches. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 5. After the above-noted development has been completed and all records associated with the claims file, the Veteran must be afforded a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran's claimed bilateral hearing loss. Any and all studies, tests, and evaluations that are deemed necessary by the VA examiner should be performed. The claims folder, including a copy of this remand, the Veteran's lay statements, the Veteran's Board hearing testimony, and medical records, should be made available and be reviewed by the examiner. Following a complete review of the record, the examiner is asked to: (a) Confirm whether there is a current diagnosis, for VA purposes, as to the Veteran's claimed bilateral hearing loss. (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's claimed bilateral hearing loss originated during, or is etiologically related to, the Veteran's active-duty service. (c) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's claimed bilateral hearing loss originated due to, or was aggravated by, a service-connected disability, to specifically include his tinnitus. (d) The examiner is asked to specifically address the Veteran's lay statements and December 2021 Board hearing testimony regarding the onset and symptoms associated with the claimed bilateral hearing loss. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 6. After the above-noted development has been completed and all records associated with the claims file, the Veteran must be afforded a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran's claimed lumbar spine, bilateral knee, bilateral elbow, and bilateral hand disabilities. Any and all studies, tests, and evaluations that are deemed necessary by the VA examiner should be performed. The claims folder, including a copy of this remand, the Veteran's lay statements, the Veteran's Board hearing testimony, and medical records, should be made available and be reviewed by the examiner. Following a complete review of the record, the examiner is asked to: (a) Confirm whether there are current diagnoses as to the Veteran's claimed: i. lumbar spine ii. left knee iii. right knee iv. left elbow v. right elbow vi. left hand vii right hand (b) Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's any diagnosed disability from section (a) originated during, or is etiologically related to, the Veteran's active-duty service. c. Provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's any diagnosed disability from section (a) originated due to, or was aggravated by, a service-connected disability. (d) The examiner is asked to specifically address the Veteran's lay statements and December 2021 Board hearing testimony regarding the onset and symptoms associated with the Veteran's claimed lumbar spine, bilateral knee, bilateral elbow, and bilateral hand disabilities. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. R. Montalvo, 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.