Citation Nr: 22018955 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 17-46 282 DATE: March 30, 2022 ORDER Service connection for a bilateral eye disability, to include constrictive visual fields, is denied. Service connection for headaches is denied. Service connection for gastroesophageal reflux disease is denied. Service connection for peripheral neuropathy of the right upper extremities is denied. Service connection for peripheral neuropathy of the left upper extremities is denied. Service connection for peripheral neuropathy of the right lower extremities is denied. Service connection for peripheral neuropathy of the left lower extremities is denied. Service connection for chloracne is denied. Entitlement to an effective date earlier than March 24, 2017, for the award of service connection for tinnitus is denied. An initial disability rating in excess of 10 percent for service-connected tinnitus is denied. REMANDED Service connection for an acquired psychiatric disability, to include unspecified depressive disorder, is remanded. Service connection for chronic obstructive pulmonary disease is remanded. Service connection for sleep apnea is remanded. Service connection for onychomycosis of the feet is remanded. FINDINGS OF FACT 1. The evidence of record does not establish that a bilateral eye disability, to include constricted vision fields, began during active service, or is otherwise related to an in-service injury or disease. 2. The evidence of record does not establish that the Veteran has had headaches at any time during or approximate to the pendency of the claim. 3. The evidence of record does not establish that the Veteran has had gastroesophageal reflux disease at any time during or approximate to the pendency of the claim. 4. The evidence of record does not establish that the Veteran has had peripheral neuropathy of the right upper extremities at any time during or approximate to the pendency of the claim. 5. The evidence of record does not establish that the Veteran has had peripheral neuropathy of the left upper extremities at any time during or approximate to the pendency of the claim. 6. The evidence of record does not establish that the Veteran has had peripheral neuropathy of the right lower extremities at any time during or approximate to the pendency of the claim. 7. The evidence of record does not establish that the Veteran has had peripheral neuropathy of the left lower extremities at any time during or approximate to the pendency of the claim. 8. The evidence of record does not establish that the Veteran has had chloracne at any time during or approximate to the pendency of the claim. 9. On March 24, 2017, the Veteran filed an initial application for service connection for tinnitus, which was not within one year of separation of service. 10. The Veteran is in receipt of the highest disability rating, 10 percent, for his service-connected tinnitus, and his symptoms are contemplated by the rating criteria. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral eye disability, to include constricted vision fields, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for headaches have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 3. The criteria for service connection for gastroesophageal reflux disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 4. The criteria for service connection for peripheral neuropathy of the right upper extremities have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 5. The criteria for service connection for peripheral neuropathy of the left upper extremities have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 6. The criteria for service connection for peripheral neuropathy of the right lower extremities have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 7. The criteria for service connection for peripheral neuropathy of the left lower extremities have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 8. The criteria for service connection for chloracne have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.309. 9. The criteria for an effective date earlier than March 24, 2017, for the award of service connection for tinnitus have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 10. The criteria for an initial disability rating in excess of 10 percent for service-connected tinnitus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.14.7, 4.21, 4.87, Diagnostic Code 6260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1967 until his honorable discharge in June 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from three sperate decision issued by a Regional Office of the United States Department of Veterans Affairs (VA), those decisions are dated January 28, 2014; May 3, 2016; and June 22, 2017. In each timely filed VA Form 9 (Substantive Appeal to the Board), he requested to testify at a Board hearing. In a correspondence dated May 11, 2021, the Board sent the Veteran and his representative advance notice of the Board hearing scheduled for September 13, 2021. Neither the Veteran nor the representative appeared for the scheduled hearing. The Veteran's representative subsequently submitted a correspondence dated December 21, 2021, indicating that after review of the Veteran's file, the appeal was considered ready to proceed to the Board for adjudication. Based on that correspondence, the Board finds that the Veteran is no longer requesting a hearing as part of his appeal. Overton v. Nicholson, 20 Vet. App. 427, 438 (2006) ("[I]t is not unreasonable to conclude that a[] [veteran's] attorney is acting with the full authority and knowledge of his client and thus, to attribute to his client the attorney's actions and communications."). Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). "[E]vidence is not in 'approximate balance' or 'nearly equal,' and therefore the benefit-of-the-doubt rule does not apply, when the evidence persuasively favors one side or the other." Lynch v. McDonough, 21 F.4th 776, 2021 U.S. App. LEXIS 37307, at *11; 2021 WL 5983923 (Fed. Cir. Dec. 17, 2021) (en banc). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. Duty to Assist There is an initial procedural matter to address. With all claims for benefits, VA has the duty to "make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claimant's claim for a benefit under a law administered by the Secretary [of VA]." 38 U.S.C. § 5103A(a)(1); see also 38 C.F.R. § 3.159(c) (implementing regulation). Part of this duty includes obtaining "relevant records held by any Federal department or agency that the claimant adequately identifies and authorizes the Secretary to obtain." 38 U.S.C. § 5103A(c)(1)(C). Pertinent to this appeal, VA's implementing regulation specifically lists Social Security Administration (SSA) records among the Federal agency records that VA is obligated to attempt to obtain. 38 C.F.R. § 3.159(c)(2). "Relevant records" are those records that relate to the injury or condition for which the veteran is seeking benefits and have a reasonable possibility of helping to substantiate the veteran's claim. Golz v. Shinseki, 590 F.3d 1317, 1321 (Fed. Cir. 2010). Because "it is not the case that a record's relevance can always be determined without reviewing the record itself," there "must be specific reason to believe [SSA] records may give rise to pertinent information to conclude that they are relevant" and, thus, give rise to VA's duty to attempt to obtain them. Id. at 1323. On June 9 and 15, 1988, VA obtained letters from the Social Security Administration. According to the information contained in the letters, the Veteran was deemed disabled under the laws of the Social Security Administration and received disability benefits. The basis for his disability benefits, however, has no relation to any of his claims for service connection. The letters indicate he became disabled on January 21, 1987, which, as discussed later within this decision, was when he was involved in a nonservice-related car accident. There is no other evidence of record that reasonably suggests the Veteran's Social Security Disability benefits have any relation to the claims before the Board on appeal. Therefore, the Board finds VA's duty to assist in obtaining those records is not implicated because any of those Social Security Administration records are not relevant, and there is no evidence to the contrary. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. A veteran who served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed to an herbicide agent unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(a)(6)(iii). If a veteran who was exposed to herbicide agents during service in the Republic of Vietnam during the Vietnam era develops certain diseases to a particular degree, as listed in 38 C.F.R. § 3.309(e), then such diseases are presumed to be due to the Veteran's herbicide agent exposure. 38 U.S.C. § 1116. Consequently, a direct medical nexus is not required. The "Vietnam era" is the period beginning on February 28, 1961, and ending on May 7, 1975, for veterans who served in the Republic of Vietnam, and the period beginning on August 5, 1964, and ending on May 7, 1975, in all other cases. 38 U.S.C. § 101(29)(A). As an initial matter, the Board finds that the Veteran did serve on the ground in Vietnam during the Vietnam Era. His military records indicate such, and the VA Regional Office has also found that the Veteran served on the ground in Vietnam. Therefore, he is presumed to have been exposed to herbicide agents. 1. Service connection for a bilateral eye disability, to include constrictive visual fields is denied. First element: A current disability In his February 2013 application for benefits, the Veteran reported a bilateral eye disability that began in the 1980s and in 1996. In January 2014, the Veteran received a VA examination assessing his asserted bilateral eye disability. The examiner diagnosed him with "constricted visual fields." The Board finds that the first element is satisfied. Second element: An in-service event, injury, or illness, or aggravation thereof Constricted visual fields are not diseases that are subject to presumptive service connection due to exposure to herbicide agents. 38 C.F.R. § 3.309(e). Thus, the evidence must establish a direct link between the Veteran's military service and his bilateral eye disability. The Veteran asserts two in-service events that he believes caused his current bilateral eye disability: (1) an in-service car accident and (2) herbicide agent exposure. As to the Veteran's assertion of an in-service car accident, the Board finds the evidence is against his assertion. The Veteran reported to the January 2014 examiner that he was in a car accident in 1967 in service, which resulted in a subsequent coma for four months. He reported undergoing rehabilitation thereafter. On review of the Veteran's military records, there is no evidence that the Veteran experienced a car accident or resulting injury in service. According to a January 1967 in-service medical record, a medical professional recorded the need for prescription glasses due to reduced visual acuity. There is no other in-service medical record addressing an eye condition. At the time of his May 1969 separation examination, the medical professional who examined the Veteran noted hyperopia and astigmatism, but there was no mention of a car accident or other eye conditions. Moreover, the Veteran did not report any eye conditions, other than the use of glasses, in his personal report of medical history in May 1969. In addition to the Veteran's military records, he submitted private medical records associated with a car accident. Importantly, the medical records are dated in 1987, not 1967. The 1987 private medical records documented that he was admitted to a rehabilitation facility following a motor vehicle accident while he was off duty as a policeman. This accident occurred just as the Veteran described to the January 2014 examiner; he said he was thrown through the windshield as a result of the car accident. The medical records document that he sustained a closed head injury and fracture to the right olecranon. The Board finds that the Veteran did not experience an in-service car accident in 1967. All relevant evidence indicates that the only car accident the Veteran experienced occurred in 1987, which was well-after after his military service ended. Had the Veteran experienced a car accident that threw him through the windshield while he was on active duty in the military, the Board finds that evidence of such a serious accident and resulting injuries would likely have been documented in his military records. The severity of his injuries that he described to the January 2014 examiner would certainly have been documented in his in-service medical records and at the time of his separation examination. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). The fact that the event he described and the injuries he sustained were similar to the same experience documented in his 1987 medical records makes it most logical to conclude that his car accidentto which he attributed his bilateral eye disabilityoccurred in 1987 outside of his active military service. Therefore, the Board finds the evidence does not establish that the Veteran experienced an in-service car accident in 1967. Hence, that nonservice-related event cannot form the basis to establish the second element of service connection. As to the second in-service event, exposure to herbicide agents, for the reasons discussed already, the Veteran is presumed to have been exposure to herbicide agents due to his service in Vietnam. Therefore, the second element is satisfied in this respect only. Third element: A causal link At the time of his January 2014 VA examination, the Veteran made no mention of his assertion that his bilateral eye disability was related to herbicide agent exposure. Thus, the examiner did not offer an opinion addressing such a link. Although no medical opinion was obtained, the Board finds that VA was not under an obligation to seek one. Section 5103A of Title 38 of the United States Code, captioned "DUTY TO ASSIST," mandates that a medical examination be provided in disability compensation claim cases only when: (1) There is competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; (2) There is evidence establishing that an event, injury, or illness occurred in service or within an applicable presumptive period, or the Veteran has a service-connected disability; and (3) There is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) There is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Each of the elements must be met. While the first two elements are satisfied, the third element is not. The third element requires that the evidence "indicate" that there "may" be a nexus between the two. This is a low threshold. McLendon, 20 Vet. App. at 83; 38 U.S.C. § 5103A(d)(2)(B). The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon, 20 Vet. App. at 83. Based on the record, the Board finds the evidence does not indicate that the Veteran's current bilateral eye disability may have a causal connection or is associated with the Veteran's active military service, to include herbicide agent exposure. The Veteran has provided only one generalized, conclusory statement that herbicide agent exposure caused his current bilateral eye disability, which is not enough to entitle him to a VA a medical examination and opinion addressing the possible link. Id. "Since all veterans could make such a statement, this theory would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations as a matter of course in virtually every veteran's disability case." Id. at 1278. Therefore, the Board finds an additional VA examination and opinion is not warranted. The Board has also considered whether the Veteran's in-service medical records suggest any relation between his current eye disability and an in-service onset. The Board observes the Veteran received glasses in service, but there was no documentation or report of constricted vision. The Board finds no evidence linking his in-service receipt of glasses to his current bilateral eye disability, and no medical professional has suggested such a link. As there is no other medical evidence of record establishing a link between the Veteran's herbicide agent exposure, or any other in-service event, injury, or disease, and his current bilateral eye disability, the third element of service connection, a causal link, is not satisfied. Accordingly, service connection for a bilateral eye disability, to include constricted visual fields, is denied. 2. Service connection for headaches is denied. 3. Service connection for gastroesophageal reflux disease is denied. 4. Service connection for peripheral neuropathy of the right upper extremities is denied. 5. Service connection for peripheral neuropathy of the left upper extremities is denied. 6. Service connection for peripheral neuropathy of the right lower extremities is denied. 7. Service connection for peripheral neuropathy of the left lower extremities is denied. 8. Service connection for chloracne is denied. The Veteran's claims for service connection for headaches, gastroesophageal reflux disease (GERD), peripheral neuropathy of the bilateral upper and lower extremities, and chloracne are addressed together because they have the same disposition supported by similar legal and factual analyses. For each of these claims for service connection, the Board finds the evidence does not establish that the Veteran has a current disability in association with each claim. In his March 24, 2017, application for service connection for these asserted disabilities, he did not provide any information in relation to each asserted disability. He did not provide any accompanying information with his application. On review of all medical records associated with his claims file, both VA and private, there is no evidence indicating that he suffers from any of his claimed disabilities. March 2015 and December 2016 VA medical notes documented that the Veteran did not experience headaches, and there are no indications he currently has headache disability. A May 2014 private medical record indicated that the Veteran had no diagnosis or symptoms associated with GERD or his digestive system in general. There is no indication that he currently has such conditions. The Veteran's medical records do not document evidence of any neuropathic disabilities or symptoms associated with his extremities. March 2015 and January 2016 VA medical notes document no skin issues or symptoms associated with chloracne. Nor is there any other medical evidence associated with the claimed disease. The Board acknowledges the Federal Circuit has held that lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson, 581 F.3d at 1316. The Federal Circuit has held that the Board can favor competent medical evidence over lay statements offered by the Veteran if the Board neither deems lay evidence categorically incompetent nor improperly requires a medical opinion as the sole way to prove causation. King v. Shinseki, 700 F.3d 1339, 1344 (2012). While the Board finds the Veteran is legally permitted to report symptoms he experiences and his lay observations, he has provided no such evidence in connection with these claims for service connection. He has only made general assertions concerning these disabilities without any evidence to support them. Without evidence showing that the Veteran has the necessary medical training or expertise to diagnose himself with these disabilities, he cannot competently state that he has a particular disability that is beyond the realm of lay observation, to include peripheral neuropathy, chloracne, and GERD. See 38 C.F.R. §§ 3.159(a)(1)(2); Jandreau v. Nicholson, 493 F.3d 1372, 1377 (Fed. Cir. 2007) (noting general competence of laypersons to testify as to symptoms but not medical diagnosis). The Board recognizes that headaches are a disability capable of lay observation, but the Veteran has offered no lay evidence to support his assertion of a headache disability. Simply stating the disability in an application is insufficient as it provides no evidence of the severity, duration, frequency, or other relevant information for which the Board can assess the credibility and probative value of his claim. See Fagan v. Shinseki, 573 F.3d 1282, 1286 (2009) (stating that the claimant has the burden to "present and support a claim for benefits" and noting that the benefit of the doubt standard in [38 U.S.C. §] 5107(b) is not applicable based on pure speculation or remote possibility). The Board finds that the first element of service connection, a current disability, is not met for each of the above claims. As there is a lack of competent evidence establishing the asserted disabilities, a VA examination and medical opinion in relation to each claim is not warranted. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters, 601 F.3d at 1277; McLendon, 20 Vet. App. 79. Accordingly, service connection for a headache disability, GERD, peripheral neuropathy of the bilateral upper and lower extremities, and chloracne is denied. Effective Dates 38 U.S.C. § 5110, which governs the assignment of an effective date for an award of benefits, provides: Unless specifically provided otherwise in this chapter, the effective date of an award based on an initial claim, or a supplemental claim, of compensation, dependency and indemnity compensation, or pension, shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor. 38 U.S.C. § 5110(a)(1). The implementing regulation similarly provides that the effective date generally "will be the date of receipt of the claim or the date entitlement arose, whichever is later." 38 C.F.R. § 3.400. An exception to this rule exists. If a veteran files a claim for service connection for a disability within one year of discharge from active duty, and receives an award of service connection, then the effective date for such award will be "the day following the date of the veteran's discharge[.]" 38 U.S.C. § 5110(b)(1). Analysis 9. Entitlement to an effective date earlier than March 24, 2017, for the award of service connection for tinnitus is denied. The Veteran filed his initial application for service connection for tinnitus on March 24, 2017. He was granted service connection for tinnitus in a June 22, 2017, decision. The VA Regional Office assigned an effective date of March 24, 2017. As the Veteran's initial application was received March 24, 2017, there is no legal basis for him to receive an effective date earlier than that. 38 U.S.C. § 5110(a)(1). He separated from military service in 1969, and his application for service connection was received beyond one year from his separation from service. He makes not arguments as to why he believes he is entitled to an earlier effective date. Accordingly, an effective date earlier than March 24, 2017, for the award of service connection for tinnitus is denied. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Diagnostic codes are assigned to individual disabilities. Diagnostic codes provide rating criteria specific to a particular disability. If two diagnostic codes are applicable to the same disability, the diagnostic code that allows for the higher disability rating applies. 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Id. Analysis 10. An initial disability rating in excess of 10 percent for service-connected tinnitus is denied. Tinnitus is rated under 38 C.F.R. § 4.87, Diagnostic Code 6260, which provides only a 10 percent rating. There is no higher rating for tinnitus. The Veteran is in receipt of the highest rating. He has provided no evidence that his tinnitus should be considered under an extra-schedular analysis. His medical records, including his June 2017 VA-contract examination, do not support such an analysis because there is no evidence that his tinnitus constitutes an exceptional disability, such that the symptoms are beyond what the rating criteria contemplates. Thun v. Peake, 22 Vet. App. 111 (2008) (establishing steps for an extraschedular analysis), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009); see also Anderson v. Shinseki, 22 Vet. App. 423, 427 (2009) (clarifying that the "steps" described in Thun "are, in fact, elements that must be established before an extraschedular rating can be awarded"). Accordingly, an initial disability rating in excess of 10 percent for service-connected tinnitus is denied. REASONS FOR REMAND 1. Service connection for an acquired psychiatric disability, to include unspecified depressive disorder, is remanded. The Veteran filed a claim for service connection for posttraumatic stress disorder (PTSD). He received a VA examination in February 2016 addressing his claim. The examiner did not diagnose him with PTSD but rather diagnosed an unspecified depressive disorder. The examiner opined that his depressive disorder was less likely than not caused by his military service. There is some suggestion in the medical opinion that his psychiatric disorder could be caused by his traumatic brain injury that he suffered as part of his 1987 car accident. Still, there is no supporting reasoning for any of the examiner's conclusions, which causes the opinion to have no probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("It is the fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion."). Significantly, in a March 2015 VA medical note, a treating medical physician stated that the Veteran's depression likely had its onset before his traumatic brain injury. No rationale was offered by the physician. Based on the foregoing, the Board finds remand is required to obtain an addendum opinion from a qualified clinician to address the etiology of the Veteran's unspecific depressive disorder. 2. Service connection for sleep apnea is remanded. The Veteran's medical records indicate that he has trouble sleeping. According to an April 2015 VA medical note, the Veteran slept only four hours per night due to constant sleep interruptions. He stated that he could fall asleep, but he could not stay asleep, which resulted in a lack of energy and daytime fatigue. This was a regular occurrence. The Board also observes that the Veteran's psychiatric disability may play a part in his sleep issues. No VA examination or opinion was obtained as to this claim for service connection. The Board finds one is necessary and remand is thus required. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters, 601 F.3d at 1277; McLendon, 20 Vet. App. 79. 3. Service connection for chronic obstructive pulmonary disease is remanded. The Veteran's private medical physician has diagnosed him with chronic obstructive pulmonary disorder (COPD). The Veteran only cited herbicide agent exposure as the basis for his claim for service connection. The VA Regional Office denied service connection because COPD is not a disease for which presumptive service connection is available. It did not obtain a medical opinion, however, addressing whether a direct nexus exists. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (even though a presumptive service connection is precluded for a disability, a grant of service connection may be made on a direct basis). There is sufficient evidence requiring remand to obtain an examination and opinion as to the etiology of the Veteran's COPD. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters, 601 F.3d at 1277; McLendon, 20 Vet. App. 79. 4. Service connection for onychomycosis of the feet is remanded. The Veteran submitted private medical opinions from his physician, Dr. C., on August 15, 2013, and March 18, 2014, in which he stated that the Veteran had onychomycosis of his feet due to dioxin exposure. The physician did not offer any rationale for his opinion. The VA Regional Office denied service connection because this disability is not one for which presumptive service connection applies based on herbicide agent exposure. 38 C.F.R. § 3.309(e). It did not obtain a medical opinion, however, addressing whether a direct nexus exists. Combee, 34 F.3d 1039. There is sufficient evidence requiring remand to obtain an examination and opinion as to the etiology of the Veteran's onychomycosis. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters, 601 F.3d at 1277; McLendon, 20 Vet. App. 79. Accordingly, the matters are REMANDED for the following actions: 1. Obtain any of the Veteran's outstanding VA medical records and associate them with the claims file 2. After any additional records are associated with the claims file, obtain an addendum opinion from an appropriately qualified clinician to provide an opinion addressing the onset and etiology of the Veteran's unspecified depressive disorder. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide an opinion regarding whether it is at least as likely as not (50 percent probability or more) that the Veteran's unspecified depressive disorder had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include service in Vietnam. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) Statements made by the Veteran in support of his claim for service connection for an acquired psychiatric disability, received by VA on November 20, 2015. (b.) A March 3, 2015, VA medical note, in which a treating medical physician stated that the Veteran's depression likely had its onset before his traumatic brain injury. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his psychiatric disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of an acquired psychiatric disability in service or the assertion that an in-service event, injury, or illness led toa psychiatric disability. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered insufficient rationale. If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 3. After any additional records are associated with the claims file, obtain a VA examination and opinion from an appropriately qualified clinician addressing the onset and etiology of the Veteran's sleep apnea, if any. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding: (a.) Does the Veteran have a clinical diagnosis of sleep apnea? (b.) If the Veteran does have sleep apnea, whether it is at least as likely as not (50 percent probability or more) that the Veteran's sleep apnea had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include as due to herbicide agent exposure, which is presumed. The Board recognizes sleep apnea is not a disease for which presumptive service connection is available under 38 C.F.R. § 3.309(e). The Board is asking for an opinion on a direct nexus, nonetheless. Only if the Veteran becomes service-connected for an acquired psychiatric disability are the following opinions necessary. (c.) If the Veteran does have sleep apnea, whether it is at least as likely as not (50 percent probability or more) that the Veteran's sleep apnea was caused by (proximately due to or as the result of) a service-connected psychiatric disability. (d.) If the Veteran does have sleep apnea, whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's sleep apnea was aggravated by a service-connected psychiatric disability. The examiner is advised "aggravation" means any increase in the severity of the underlying disability beyond its natural progression. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his sleep apnea, if any, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of sleep apnea in service or the assertion that an in-service event, injury, or illness led to sleep apnea. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinions, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered insufficient rationale. If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 4. After any additional records are associated with the claims file, obtain a VA examination and opinion from an appropriately qualified clinician addressing the onset and etiology of the Veteran's chronic obstructive pulmonary disease (COPD), if any. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding whether it is at least as likely as not (50 percent probability or more) that the Veteran's COPD, if any, had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include as due to herbicide agent exposure, which is presumed. The Board recognizes COPD is not a disease for which presumptive service connection is available under 38 C.F.R. § 3.309(e). The Board is asking for an opinion on a direct nexus, nonetheless. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) Private physician, Dr. C.'s, medical statements received by VA on August 15, 2013, and March 21, 2014, that diagnosed the Veteran with COPD. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his claimed COPD disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of COPD or symptoms in service or the assertion that an in-service event, injury, or illness led to COPD. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered insufficient rationale. If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 5. After any additional records are associated with the claims file, obtain a VA examination and opinion from an appropriately qualified clinician addressing the onset and etiology of the Veteran's onychomycosis of the feet, if any. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding whether it is at least as likely as not (50 percent probability or more) that the Veteran's onychomycosis had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include exposure to herbicide agents in Vietnam, which is presumed. The Board recognizes onychomycosis is not a disease for which presumptive service connection is available under 38 C.F.R. § 3.309(e). The Board is asking for an opinion on a direct nexus, nonetheless. In rending his or her opinion, the examiner should consider and, if deemed relevant, address the following, in addition to any other relevant evidence: (a.) Private physician, Dr. C.'s, medical statements received by VA on August 15, 2013, and March 21, 2014, that diagnosed the Veteran with onychomycosis due to dioxin exposure. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of onychomycosis in service or the assertion that an in-service event, injury, or illness led to onychomycosis. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion, including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be considered an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, may be considered insufficient rationale. If the examiner relies on medical treatises, the examiner should identify the treatises. (Continued on the next page) If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, 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.