Citation Nr: 23064458 Decision Date: 12/05/23 Archive Date: 12/05/23 DOCKET NO. 20-12 572 DATE: December 5, 2023 ORDER Entitlement to a compensable disability rating for status post bilateral hemiphalangectomy (also claimed as feet/bilateral fifth toes) is dismissed. As new and material evidence has been received, the claim for service connection for headaches, is reopened. As new and material evidence has been received, the claim for service connection for right ankle disorder is reopened. As new and material evidence has been received, the claim for service connection for left ankle disorder is reopened. As new and material evidence has been received, the claim for service connection for the right shoulder disorder is reopened. As new and material evidence has been received, the claim for service connection for left shoulder disorder is reopened. As new and material evidence has been received, the claim for service connection for gastroesophageal reflux disease (GERD) is reopened. As new and material evidence has been received, the claim for service connection for hypertension is reopened. As new and material evidence has been received, the claim for service connection for throat disorder is reopened. As new and material evidence has been received, the claim for service connection for sinus disorder is reopened. As new and material evidence has been received, the claim for service connection for a nose disorder claimed as rhinitis is reopened. As new and material evidence has been received, the claim for service connection for disability claimed as dizziness is reopened. As new and material evidence has been received, the claim for service connection for obstructive sleep apnea (OSA) is reopened. Entitlement to service connection for OSA is granted. Entitlement to service connection for GERD is granted. Entitlement to service connection for headaches is granted. Entitlement to service connection for sinusitis is granted. Entitlement to service connection for rhinitis is granted. REMANDED Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a chronic disability of the right shoulder is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a throat disorder is remanded. Entitlement to service connection for a right ankle disorder is remanded. Entitlement to service connection for a left ankle is remanded. Entitlement to service connection for a disability claimed as dizziness is remanded. Entitlement to a disability rating greater than 10 percent for Grave's disease, status post radiation with residual hypothyroidism, is remanded. Entitlement to a disability rating greater than 10 percent for degenerative arthritis, right knee is remanded. Entitlement to a disability rating greater than 10 percent for degenerative arthritis, left knee is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. At the June 2021 Board hearing, prior to the promulgation of a decision in the appeal, the Veteran withdrew the issue of a compensable disability rating for status post bilateral hemispherectomies (also claimed as feet/bilateral fifth toes). 2. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for headaches. 3. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for right ankle disorder. 4. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for a left ankle disorder. 5. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for a right shoulder disorder. 6. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for a left shoulder disorder. 7. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for GERD. 8. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for hypertension. 9. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for a throat disorder. 10. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for a sinus disorder. 11. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for rhinitis. 12. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for disability claimed as dizziness. 13. Evidence associated with the claims file since the July 2016 rating decision is new and raises a reasonable possibility of substantiating the claim for entitlement to service connection for OSA. 14. The competent and credible medical evidence reflects that the Veteran's OSA began in service. 15. The competent and credible medical evidence reflects that the Veteran's GERD began in service. 16. The Veteran's headache disorder is aggravated by her service-connected depression. 17. The Veteran's sinusitis is caused by her herein service-connected GERD. 18. The Veteran's rhinitis is caused by her herein service-connected GERD. CONCLUSIONS OF LAW 1. The criteria for withdrawal of a compensable disability rating for status post bilateral hemispherectomies (also claimed as feet) have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for reopening a final denial of service connection for headaches have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for reopening a final denial of service connection for a right ankle disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 4. The criteria for reopening a final denial of service connection for a left ankle disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 5. The criteria for reopening a final denial of service connection for a right shoulder disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 6. The criteria for reopening a final denial of service connection for a left shoulder disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 7. The criteria for reopening a final denial of service connection for GERD have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 8. The criteria for reopening a final denial of service connection for hypertension have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 9. The criteria for reopening a final denial of service connection for a throat have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 10. The criteria for reopening a final denial of service connection for sinus disorder have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 11. The criteria for reopening a final denial of service connection for rhinitis have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 12. The criteria for reopening a final denial of service connection for disability claimed as dizziness have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 13. The criteria for reopening a final denial of service connection for OSA have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 14. The criteria for service connection for OSA have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 15. The criteria for service connection for GERD have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 16. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 17. The criteria for service connection for sinusitis have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 18. The criteria for service connection for rhinitis have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1981 to May 1992. These matters are before the Board on appeal from a February 2018 rating decision by a Department of Veterans Affairs (VA) regional office (RO). In June 2021, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A copy of the transcript is of record. As part of the underlying increased rating claim, the Board had jurisdiction to consider entitlement to a TDIU. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). A TDIU claim is considered reasonably raised when a veteran submits medical evidence of a disability, makes a claim for the highest rating possible, and submits evidence of service-connected unemployability. Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001); Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009); Payne v. Wilkie, 31 Vet. App. 373 (2019); Harper v. Wilkie, 30 Vet. App. 356 (2018). The Board notes that the record contains a January 2019 Privacy Act request submitted by the Veteran's representative requesting all documents, including those in the paper claims folder and electronic folders. The Board, however, considers this request duplicative, as all the Veterans' documents are housed in an electronic claims file, which the representative already has access to, including the requested records, via the Veterans Benefits Management System (VBMS). Therefore, the attorney's request for access to the identified documents has already been fulfilled, and no further action is required. I. Entitlement to a compensable disability rating for status post bilateral hemiphalangectomy (also claimed as feet/ bilateral fifth toes) is dismissed. The Board may dismiss any appeal that does not allege a specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105(d). An appeal may be withdrawn as to any or all issues involved in the appeal and may be made by the appellant or the authorized representative. 38 C.F.R. § 19.55. Regarding oral withdrawals, "withdrawal of a claim is only effective where the withdrawal is explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant." Delisio v. Shinseki, 25 Vet. App. 45, 57 (2011). A Board determination that a [veteran] withdrew her appeal must include a "finding regarding whether [she] understood the consequences of withdrawing h[er] claims." Acree v. O'Rourke, 891 F.3d 1009, 1015 (Fed. Cir. 2018). Here, the Veteran's representative, in the June 2021 Board hearing, requested the withdrawal of the issue of a compensable disability rating for status post bilateral hemiphalangectomy (also claimed as feet/bilateral fifth toes). The Veteran specifically testified to not having "any problem with [her] toes right now. Not my toes, but my ankle and the heel of my feet." Based on the Veteran's testimony, the Board finds she withdrew her appeal understating the consequences of withdrawing her appeal of this issue. Moreover, the Veteran was represented at the hearing by an attorney who by education, training, and practice fully understood the consequences of withdrawing. Dismissal of this appeal is therefore appropriate in these circumstances. Thus, the Board finds that the Veteran has withdrawn her appeal for a compensable disability rating for status post bilateral hemiphalangectomy. Accordingly, the Board does not have jurisdiction to review the appeal, and thus, the appeal is dismissed. II. New and Material 1. As new and material evidence has been received to reopen the claim for service connection for headaches, the claim is reopened. 2. As new and material evidence has been received to reopen the claim for service connection for right ankle disorder, the claim is reopened. 3. As new and material evidence has been received to reopen the claim for service connection for left ankle disorder, the claim is reopened. 4. As new and material evidence has been received to reopen the claim for service connection for the right shoulder, the claim is reopened. 5. As new and material evidence has been received to reopen the claim for service connection for left shoulder disorder, the claim is reopened. 6. As new and material evidence has been received to reopen the claim for service connection for GERD, the claim is reopened. 7. As new and material evidence has been received to reopen the claim for service connection for hypertension, the claim is reopened. 8. As new and material evidence has been received to reopen the claim for service connection for throat disorder, the claim is reopened. 9. As new and material evidence has been received to reopen the claim for service connection for sinus disorder, the claim is reopened. 10. As new and material evidence has been received to reopen the claim for service connection for a nose disorder claimed as rhinitis, the claim is reopened. 11. As new and material evidence has been received to reopen the claim for service connection for disability claimed as dizziness, the claim is reopened. 12. As new and material evidence has been received to reopen the claim for service connection for OSA, the claim is reopened. A rating decision of April 1994 denied service connection for headaches, finding that the disorder was temporary and resolved with treatment, and no permanent residual disability was shown at the time of separation. The Veteran filed a notice of Disagreement (NOD) in December 1994, contesting the denial. In April 1995, a Statement of the Case (SOC) was issued. As the Veteran did not provide new and material evidence or appeal the continued denial to the Board of Veteran's Appeals within 60 days of the SOC, the rating decision of April 1994 is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160(d), 20.1103. A rating decision of June 2010 denied service connection for left shoulder impingement syndrome based on examination findings that it was not the result of service. A March 2015 rating decision denied service connection for a bilateral ankle disorder (claimed as ankle pain), finding that the disorder was incurred in or caused by service. The Veteran was informed of the June 2010 and March 2015 rating decisions and her appellate rights. She neither provided a NOD nor additional evidence within one year of the rating decisions. Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2011); Bond v. Shinseki, 659 F.3d 1362, 1367-68 (Fed. Cir. 2011). Hence, the rating decisions of June 2010 and March 2015 are final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.160 (d), 20.1103. In April 2016, the Veteran filed an Application for Disability Compensation and Related Compensation Benefits requesting to reopen claims for headaches, bilateral ankle, and left shoulder disorders. In a rating decision of July 2016, the RO indicated that as no new and material evidence was submitted, the claims were denied. In the said July 2016 rating decision, the RO additionally denied service connection for right shoulder disorder, throat disorder, sinus disorder, rhinitis, GERD, disability claimed as dizziness, OSA, and hypertension. Later, in July 2016, the Veteran filed an Application for Disability Compensation and Related Compensation Benefits requesting to reopen claims for left shoulder disorder, sinus disorder, rhinitis, GERD, and hypertension. The Veteran also indicated having had treatment at Bethesda Naval Hospital from 1982 to 1985, NSA Naval Hospital/Italy from 1988 to 1990, Palo Alto VA Clinic from 1993 to 1999, East Orange NJ VAMC from 2000 to 2013, and VAMC Brooklyn in 2013. The RO, in September 2016, requested that the Veteran provide the documents from the above facilities or a release therefor. In September 2016, the Veteran filed another Application for Disability Compensation and Related Compensation Benefits requesting to reopen claims for left shoulder disorder, right shoulder disorder, headaches, bilateral ankle disorder, sinus disorder, rhinitis, GERD, a throat disorder, OSA, dizziness, and hypertension. The Veteran reported treatment at various VAMCs, including VA San Francisco Hospital, from 1993 to 1999. In an October 2016 correspondence, the RO acknowledged the Veteran's request to reopen claims for left shoulder disorder, right shoulder disorder, headaches, bilateral ankle disorder, sinus disorder, rhinitis, GERD, a throat disorder, OSA, disability claimed as dizziness, and hypertension. The RO noted the previous denials of July 2016 and the appeal rights, including new and material evidence submission, a NOD, and identifying clear and unmistakable errors in a previous rating decision. Also, in October 2016, various medical records request rejection notices were associated with the claims file. As the Veteran was informed of her appellate rights in the July 2016 rating decision and she provided no NOD nor additional evidence within one year, the rating decision of July 2016 is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.160(d), 20.1103. The Board notes the Veteran indication of treatment at various VA facilities, during and after service. However, many were already of file and VA attempted to obtain any identified outstanding records and notified the Veteran in October 2016 of the records request rejection notices. While some outstanding records were associated with the claims file, they were not relevant to the issues on appeal. Thus, as in the absence of a timely NOD or new and material evidence the rating decision of July 2016 is final. A rating decision of February 2018 reopened the claims for GERD, hypertension, left ankle, right ankle, left shoulder, right shoulder, throat disorder, headaches, rhinitis, sinus, dizziness, and OSA, and nonetheless, continued the denials. In December 2017, the Veteran provided a NOD, contesting the denials. In February 2020, a Statement of the Case (SOC) was issued. The Board has no jurisdiction to consider a claim based on the same factual basis as a previously disallowed claim. 38 U.S.C. § 7104(b); King v. Shinseki, 23 Vet. App. 464 (2010); DiCarlo v. Nicholson, 20 Vet. App. 52, 55 (2006) (holding that res judicata generally applies to VA decisions). However, the finality of a previously disallowed claim can be overcome by submitting new and material evidence. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means 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 prior 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 to decide whether a claim should be reopened, "the credibility of the evidence is to be presumed." Savage v. Gober, 10 Vet. App. 488 (1997); Justus v. Principi, 3 Vet. App. 510, 513 (1992). Only in cases in which the newly submitted evidence is "inherently false or untrue" does the presumption of credibility not apply. Duran v. Brown, 7 Vet. App. 216, 220 (1994). The evidence obtained more than one year after the July 2016 rating decision relating to the Veteran's GERD, hypertension, left ankle, right ankle, left shoulder, right shoulder, throat disorder, headaches, rhinitis, sinus disorder, disability claimed as dizziness, and OSA includes additional lay statements, VA treatment records, a private medical opinion, and Board hearing testimony. This evidence tends to prove or disprove elements of the claims and, therefore, is new and material; reopening is warranted. The Board finds that the evidence received since the July 2016 rating decision is new and material and raises a reasonable possibility of substantiating the claims. As such, the claims are, thus, reopened. 38 U.S.C. § 5107; Annoni v. Brown, 5 Vet. App. 463 (1993). III. Service connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). A secondary service connection may also be established for a nonservice-connected disability aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing before the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). To establish entitlement to service connection on a secondary basis, there must be (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509 (1998). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331(Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence considering the entirety of the record. In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b). 1. Entitlement to service connection for OSA is granted. 2. Entitlement to service connection for GERD is granted. 3. Entitlement to service connection for chronic headaches is granted. 4. Entitlement to service connection for sinusitis is granted. 5. Entitlement to service connection for rhinitis is granted. The Veteran has been diagnosed with headaches, OSA, GERD, rhinitis, and sinusitis. She contends that the disabilities are a result of service. In the alternative, she argues that they are secondarily related to her service-connected Grave's disease and/or acquired psychiatric disorder. The Veteran was afforded a VA examination and opinion in October 2019 to address the etiology of OSA. The examiner proffered a negative nexus opinion to service and explained that there was no evidence of OSA symptoms in the service treatment records (STRs), and while she reported issues with snoring and gasping, it was highly unlikely that she continued with sleep apnea for over 20 years without a diagnosis. As the examiner failed to address the lay statements of record, including from her partner, G.C., and fellow service member, C.D., and the secondary service connection theory, this opinion is inadequate. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The Veteran provided positive nexus opinions from Dr. M.B.S., M.D., in June 2021, who, in support thereof, noted a thorough review of the Veteran's medical records, including treatment records from the VA. Dr. M.B.S, M.D. explained that the Veteran's OSA and GERD symptoms began in service and continued. In support thereof, he cited the lay statements of record, including from the Veteran, her partner, G.C., and fellow service member, C.D. Regarding the headaches, Dr. M.B.S., M.D. found that the Veteran's headaches were aggravated by her depression and cited clinical studies in support thereof. Lastly, he explained that the Veteran's GERD caused rhinitis and sinusitis as the gastro acid is pushed into the upper airway and chronic inflammation therefrom is created within the nasopharyngeal passageway. The Board affords the opinions provided by Dr. M.B.S. great probative weight, considering he specifically noted a thorough review of the claims file and medical records and provided a thorough rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (holding that a physician should have information regarding relevant case facts.) Furthermore, there are no competent contrary opinions of record. Resolving all reasonable doubt in the Veteran's favor, the most persuasive evidence weighs in favor of finding that the Veteran's OSA and GERD are etiologically related to her active-duty service. Regarding headaches, rhinitis, and sinusitis, the elements of a secondary service connection are satisfied. Wallin, 11 Vet. App. 509, 512 (1998). Accordingly, the Board finds that granting service connection is the decision that is the most consistent with the VA's policy to administer the law under a broad and liberal interpretation consistent with the facts of the case. 38 C.F.R. §§ 3.303, 3.310. REASONS FOR REMAND 1. Entitlement to service connection for hypertension is remanded. The Veteran has been diagnosed with hypertension. She contends that it was a result of service. In the alternative, she argues a secondary relationship to her service-connected Grave's disease and/or acquired psychiatric disorder. The Veteran was afforded VA examinations and opinion in October 2019 to determine the etiology of her hypertension. The examiner proffered a negative nexus opinion and explained that Grave's disease, diagnosed in 2004, did not cause hypertension as it was diagnosed in 2006, two years later. The examiner did not address the aggravation prong of a secondary service connection claim, the opinion is also inadequate. Atencio v. O'Rourke, 30 Vet. App. 74 (2018). The Veteran provided positive nexus opinion from Dr. M.B.S., M.D., in June 2021 in support of her secondary theory. However, although Dr. M.B.S, M.D. found that hypertension was a direct result of service-connected hypothyroidism and depression, he explained they caused weight gain, which then resulted in hypertension. While obesity may serve as an "intermediate step" between a service-connected disability and a current disability, three elements must first be shown: that the Veteran's service-connected disabilities caused or aggravated her obesity; the obesity was a substantial factor in causing her hypertension; and that the hypertension would not have occurred but for the obesity caused or aggravated by her service-connected disabilities. See VAOGCPREC 1-2017; Walsh v. Wilkie, 32 Vet. App. 300 (2020). As there is no competent medical evidence of record addressing these questions, a remand is warranted for a supplemental medical opinion. 2. Entitlement to service connection for a right shoulder disorder is remanded. 3. Entitlement to service connection for a left shoulder disorder is remanded. 4. Entitlement to service connection for a right ankle disorder is remanded. 5. Entitlement to service connection for a left ankle disorder is remanded. 6. Entitlement to service connection for a disability claimed as dizziness is remanded. 7. Entitlement to service connection for a throat disorder is remanded. The Veteran's claims for service connection for disorders of the right ankle, left ankle, right shoulder, left shoulder, disability claimed as dizziness, and throat due to service. In the alternative, there may be a relationship between her disabilities and her service-connected Grave's disease. As the claims have been reopened herein and the Veteran has not been afforded VA examinations to address the etiologies thereof, a remand is warranted. 8. Entitlement to a disability rating greater than 10 percent for Grave's disease, status post radiation with residual hypothyroidism is remanded. 9. Entitlement to a disability rating greater than 10 percent for degenerative arthritis, right knee is remanded. 10. Entitlement to a disability rating greater than 10 percent for degenerative arthritis, left knee is remanded. The Veteran's last VA examinations were in October 2019, and the Veteran competently and credibly testified to a worsening. As such, current examinations are warranted to determine the severity of her disabilities. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The duty to conduct a contemporaneous examination is triggered when the evidence indicates that there has been a material change in disability and the available evidence is too old or that the current rating may be incorrect. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); Caffrey v. Brown, 6 Vet. App. 377, 381 (1995); 38 C.F.R. § 3.326(a). Specifically, addressing her Grave's disease, the Veteran testified to first being diagnosed with hyperthyroidism, which later turned into hypothyroidism. The medical records confirm a diagnosis of hypothyroidism. While her disability is currently rated under Diagnostic Code 7900 for hyperthyroidism, the Veteran has testified to increased symptoms, including fatiguability and hypertension, even with her taking the prescribed Levothyroxine medication for her Grave's disease. As the medical and lay evidence of record reflects a worsening, of her disability, a remand is warranted for a VA examination to determine the current severity thereof. 11. Entitlement to a TDIU is remanded. TDIU is remanded as inextricably intertwined with the service connection and increased rating claims being remanded. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both issues have been considered); Tyrues v. Shinseki, 23 Vet. App. 166, 178 (2009). Accordingly, the matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding private and VA treatment records. 2. Provide the Veteran's claim file to a qualified clinician so that a supplemental opinion may be provided to determine the etiology of her hypertension. The entire claims file must be made available to the clinician for review. A physical examination of the Veteran or a telehealth examination is only required if deemed necessary by the clinician. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's June 2021 hearing testimony. The examiner must provide an opinion regarding the following: a. Whether the Veteran's hypertension had its onset in and/or is otherwise etiologically related to her period of active service or began within one year after discharge. b. Whether the Veteran's hypertension is due to or the result of her service-connected thyroid disorder. c. Whether the Veteran's disability hypertension is aggravated by her service-connected thyroid disorder. d. Whether the Veteran's service-connected disabilities caused her to become obese or aggravated her obesity. e. If the answer to (d) is yes, whether the Veteran's obesity was a substantial factor in causing her hypertension. f. If the answer to (e) is yes, whether the Veteran's hypertension would not have occurred but for obesity that was caused by or aggravated by her service-connected disabilities. The examiner is reminded that for the examination to be adequate, the medical opinion must provide explanations for both the aggravation and causation prongs of a secondary service connection claim. Atencio, 30 Vet. App. 74 (2018). For the purposes of this remand only and for the limited purpose of conducting the examination and providing the above medical opinions, the examiner should assume that the Veteran's statements are true. If there is a medical reason to doubt its veracity, the examiner should explain why the Veteran's recollection is inconsistent with the principles of medical science and/or the evidence in this case. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resorting to speculation, the examiner must state this and provide a rationale for such a conclusion. 3. Provide the Veteran's claim file to a qualified clinician so that an examination may be provided to determine the etiology of her bilateral shoulder and ankle disorders. The entire claims file must be made available to the examiner for review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's June 2021 hearing testimony. Bilateral shoulder a. Whether the Veteran's right shoulder disorder had its onset in and/or is otherwise etiologically related to her period of active service; if arthritis is diagnosed, whether it was within one year of service. b. Whether the Veteran's left shoulder disorder had its onset in and/or is otherwise etiologically related to her period of active service; if arthritis is diagnosed, whether it was within one year of service. c. Whether the Veteran's right shoulder disorder is due to or the result of her service-connected thyroid disorder. d. Whether the Veteran's left shoulder disorder is due to or the result of her service-connected thyroid disorder. e. Whether the Veteran's right shoulder disorder is aggravated by her service-connected thyroid disorder. f. Whether the Veteran's left shoulder disorder is aggravated by her service-connected thyroid disorder. Bilateral ankle a. Whether the Veteran's right ankle disorder had its onset in and/or is otherwise etiologically related to her period of active service; if arthritis is diagnosed, whether it was within one year of service. b. Whether the Veteran's left ankle disorder had its onset in and/or is otherwise etiologically related to her period of active service; if arthritis is diagnosed, whether it was within one year of service. c. Whether the Veteran's right ankle disorder is due to or the result of her service-connected thyroid disorder. d. Whether the Veteran's left ankle disorder is due to or the result of her service-connected thyroid disorder. e. Whether the Veteran's right ankle disorder is aggravated by her service-connected thyroid disorder. f. Whether the Veteran's left ankle disorder is aggravated by her service-connected thyroid disorder. The examiner is reminded that for the examination to be adequate, the medical opinion must provide explanations for both the aggravation and causation prongs of a secondary service connection claim. Atencio, 30 Vet. App. 74 (2018). For the purposes of this remand only and for the limited purpose of conducting the examination and providing the above medical opinions, the examiner should assume that the Veteran's statements are true. If there is a medical reason to doubt its veracity, the examiner should explain why the Veteran's recollection is inconsistent with the principles of medical science and/or the evidence in this case. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resorting to speculation, the examiner must state this and provide a rationale for such a conclusion. 4. Provide the Veteran's claim file to a qualified clinician so that an examination may be provided to determine the etiology of her disability claimed as dizziness. The entire claims file must be made available to the examiner for review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's June 2021 hearing testimony. The examiner must provide an opinion regarding the following: a. Whether the Veteran's disability claimed as dizziness had its onset in and/or is otherwise etiologically related to her period of active service. b. Whether the Veteran's disability claimed as dizziness is due to or the result of her service-connected thyroid disorder. c. Whether the Veteran's disability claimed as dizziness is aggravated by her service-connected thyroid disorder. The examiner is reminded that for the examination to be adequate, the medical opinion must provide explanations for both the aggravation and causation prongs of a secondary service connection claim. Atencio, 30 Vet. App. 74 (2018). For the purposes of this remand only and for the limited purpose of conducting the examination and providing the above medical opinions, the examiner should assume that the Veteran's statements are true. If there is a medical reason to doubt its veracity, the examiner should explain why the Veteran's recollection is inconsistent with the principles of medical science and/or the evidence in this case. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resorting to speculation, the examiner must state this and provide a rationale for such a conclusion. 5. Provide the Veteran's claim file to a qualified clinician so that an examination may be provided to determine the etiology of her disability claimed as a throat disorder. The entire claims file must be made available to the examiner for review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's June 2021 hearing testimony. The examiner must provide an opinion regarding the following: a. Whether the Veteran's disability claimed as a throat disorder had its onset in and/or is otherwise etiologically related to her period of active service. b. Whether the Veteran's disability claimed as a throat disorder is due to or the result of her service-connected thyroid disorder. c. Whether the Veteran's disability claimed as a throat disorder is aggravated by her service-connected thyroid disorder. The examiner is reminded that for the examination to be adequate, the medical opinion must provide explanations for both the aggravation and causation prongs of a secondary service connection claim. Atencio, 30 Vet. App. 74 (2018). For the purposes of this remand only and for the limited purpose of conducting the examination and providing the above medical opinions, the examiner should assume that the Veteran's statements are true. If there is a medical reason to doubt its veracity, the examiner should explain why the Veteran's recollection is inconsistent with the principles of medical science and/or the evidence in this case. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above-requested opinions cannot be made without resorting to speculation, the examiner must state this and provide a rationale for such a conclusion. 6. Provide the Veteran's claims file to a qualified clinician so that a VA examination may be provided to determine the current severity of her Grave's Disease. The entire claims file must be made available to the clinician for review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's June 2021 hearing testimony. 7. Provide the Veteran's claim file to a qualified clinician so that a VA examination may be provided to determine the current severity of her bilateral knee disorder. The entire claims file must be made available to the clinician for review. Although an independent review of the claims file is required, the Board calls the clinician's attention to the Veteran's June 2021 hearing testimony of swollen knees and having to get shots for knees. 8. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. DUSTIN L. WARE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Stevens, Counsel