Citation Nr: A25035205 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 240221-418101 DATE: April 16, 2025 ORDER Service connection for a left elbow condition is denied. Service connection for a left shoulder condition is denied. Service connection for a left hip condition is denied. Service connection for a right hip condition is denied. Service connection for hypertension is denied. An effective date of October 26, 2021, for the award of service connection for migraine/headaches is granted. An effective date earlier than October 26, 2021, for the assignment of a 70 percent rating for posttraumatic stress disorder (PTSD) is denied. An effective date earlier than October 26, 2021, for the assignment of a 20 percent rating for right shoulder separation is denied. An effective date earlier than October 26, 2021, for the assignment of a 10 percent rating for right elbow strain is denied. An effective date earlier than September 12, 2022, for the award of a separate rating for right knee instability, associated with right knee osteoarthritis, is denied. An effective date earlier than September 12, 2022, for the award of a separate rating for right knee limitation of extension, associated with right knee osteoarthritis, is denied. A compensable rating for hiatal hernia, to include an earlier effective date, is denied. REMANDED Entitlement to service connection for lumbar strain, to include as secondary to the service-connected bilateral knee disabilities, is remanded. Entitlement to service connection for left lower extremity radiculopathy/sciatica, to include as secondary to the claimed lumbar strain, is remanded. Entitlement to service connection for right lower extremity radiculopathy/sciatica, to include as secondary to the claimed lumbar strain, is remanded. Entitlement to service connection for cardiomyopathy with ventricular arrhythmias, to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected disabilities, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected PTSD, is remanded. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that the Veteran has had a diagnosis of a left elbow condition, left shoulder condition, left hip condition, right hip condition, or hypertension at any time during or approximate to the pendency of the claims for service connection. 2. The Veteran submitted two Intent to File a Claim for Compensation ("Intent to File") forms that were received on October 26, 2021, and November 23, 2021; and he submitted a claim for service connection for headaches in December 2021. No formal or informal claim for service connection for headaches was received prior to October 26, 2021. 3. Service connection for PTSD was granted in an August 2020 rating decision, with an initial 30 percent rating assigned effective March 26, 2020. The Veteran did not appeal the decision. 4. The Veteran submitted an Intent to File and a claim for an increased rating for PTSD on October 26, 2021. 5. There is no evidence in the claims file dated between August 2020 and October 26, 2021, that the Veteran filed a claim for an increased rating for PTSD, and it is not factually ascertainable that a 70 percent rating was warranted before October 26, 2021. 6. Service connection for right shoulder separation and irregularity of the right elbow radial head were granted in a March 2005 rating decision, with a 10 percent rating assigned to the right shoulder and a noncompensable rating assigned to the right elbow, both effective March 15, 2005. The Veteran did not appeal the right elbow issue. 7. The Veteran requested an increased rating for the right shoulder in January 2006. The 10 percent rating was continued in a June 2006 rating decision. The Veteran did not appeal the issue. 8. The Veteran submitted an Intent to File and claims for increased ratings for the right shoulder and right elbow on October 26, 2021. 9. There is no evidence in the claims file dated between June 2006 and October 26, 2021, that the Veteran filed a claim for an increased rating for the right shoulder, and it is not factually ascertainable that a 20 percent rating was warranted before October 26, 2021. 10. There is no evidence in the claims file dated between March 2005 and October 26, 2021, that the Veteran filed a claim for an increased rating for the right elbow, and it is not factually ascertainable that a 10 percent rating was warranted before October 26, 2021. 11. Service connection for right knee retropatellar pain was granted in a March 2005 rating decision, with a 10 percent rating assigned under Diagnostic Code 5099-5262 effective March 15, 2005. In January 2006, the Veteran requested an increased rating for the right knee, which was denied in a June 2006 rating decision. The Veteran did not appeal the issue. 12. The Veteran submitted an Intent to File and a claim for an increased rating for the right knee on October 26, 2021. In a December 2021 rating decision, the 10 percent rating was continued for the right knee disability, recharacterized to right knee osteoarthritis, under Diagnostic Code 5010-5262. 13. On September 19, 2022, the Veteran requested an increased rating for the right knee. In an October 2022 rating decision, two additional 10 percent ratings were granted for instability (Diagnostic Code 5257) and limitation of extension (Diagnostic Code 5261), both effective September 19, 2022. 14. In a July 2023 rating decision, an earlier effective date of September 12, 2022, was granted for the right knee instability and right knee limitation of extension. 15. There is no evidence in the claims file dated between June 2006 and October 26, 2021, that the Veteran filed a claim for an increased rating for the right knee, and it is not factually ascertainable that 10 percent ratings were warranted for right knee instability or limitation of extension before September 19, 2022. 16. For the entire period of appeal, the hiatal hernia results in pyrosis. CONCLUSIONS OF LAW 1. The criteria for service connection for a left elbow condition 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 a left shoulder condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a left hip condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a right hip condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for an earlier effective date of October 26, 2021, for the grant of service connection for migraine/headaches have been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § § 3.105, 3.155, 3.400. 7. The criteria for an effective date earlier than October 26, 2021, for the grant of a 70 percent rating for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.155, 3.157, 3.159, 3.400. 8. The criteria for an effective date earlier than October 26, 2021, for the grant of a 20 percent rating for right shoulder separation have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.155, 3.157, 3.159, 3.400. 9. The criteria for an effective date earlier than October 26, 2021, for the grant of a 10 percent rating for right elbow strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.155, 3.157, 3.159, 3.400. 10. The criteria for an effective date earlier than September 12, 2022, for the grant of a 10 percent rating for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.155, 3.157, 3.159, 3.400. 11. The criteria for an effective date earlier than September 12, 2022, for the grant of a 10 percent rating for right knee limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.155, 3.157, 3.159, 3.400. 12. The criteria for a compensable rating for hiatal hernia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.114, Diagnostic Code 7346 (prior to May 19, 2024). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from August 2001 to March 2005. In the February 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. The Board notes that the Veteran initially requested Higher-Level Review (HLR) of August, September, and October 2022 rating decisions. In a July 2023 rating decision, the higher level reviewer adjudicated the earlier effective date and increased rating issues on appeal, and determined that there had been duty to assist errors with regard to the service connection claims. The higher level reviewer then transferred the service connection claims to the Supplemental Claim decision review option for additional development, and denied the claims in a December 2023 rating decision. Therefore, the Board may only consider the evidence of record at the time of the August, September, and October 2022 agency of original jurisdiction (AOJ) rating decisions with regard to the earlier effective dates and increased rating claims on appeal, and the December 2023 rating decision with regard to the service connection claims on appeal. 38 C.F.R. § 20.301. If evidence was submitted after these decisions, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310(a), (b). Certain disease, including arthritis, are listed among the "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 1. Service connection for a left elbow condition. 2. Service connection for a left shoulder condition. The Veteran contends without further elaboration that service connection is warranted for a left elbow condition and left shoulder condition. Service treatment records (STRs) indicate that the Veteran was in a motor vehicle accident (MVA) in August 2002; however, they are silent for mention of any complaints, diagnosis, or treatment of any left elbow or left shoulder condition. Post-service VA treatment records consistently note that the Veteran had a history of right shoulder and elbow pain, but are silent for mention of complaints, diagnosis, or treatment of any left elbow or left shoulder condition. The Board notes that the Veteran has not been afforded VA examinations for these claimed disabilities. Under applicable law, a medical examination and/or opinion is deemed "necessary" if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent lay or medical evidence of a current diagnosed disability or persistent or recurrent symptoms of disability; (2) establishes that the veteran suffered an event, injury, or disease in service, or has a disease or symptoms of a disease listed in 38 C.F.R. §§ 3.309, 3.313, 3.316, and 3.317 manifesting during an applicable presumptive period, provided the claimant has the required service or triggering event to qualify for that presumption; and (3) indicates that the claimed disability or symptoms may be associated with the established event, injury, or disease in service or with another service-connected disability. 38 C.F.R. § 3.159(c)(4). Here, there is no competent and credible evidence event suggesting that the Veteran has any symptoms or diagnosis related to a left elbow condition or left shoulder condition that is related to service. As such, VA examinations are not required. In sum, the probative evidence of record weighs against the claims for service connection for a left elbow condition and a left shoulder condition. As such, there is no benefit of the doubt to resolve in the Veteran's favor. See Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). 3. Service connection for a left hip condition. 4. Service connection for a right hip condition. The Veteran contends that the claimed bilateral hip condition started in 2002 with a gradual onset of pain, and/or that it is due to an August 2002 in-service MVA. See the January and July 2022 VA hip and thigh conditions examination reports. As noted above, STRs indicate that the Veteran was in a MVA in August 2002. A September 2002 bone scan of the lower extremities done due to complaints of bilateral knee pain showed normal hips. In June 2004, the Veteran reported that he had hip pain "on occasion" due to the accident. An October 2004 Medical Evaluation Board report is silent for mention of any complaints or diagnosis of any hip condition. In a January 2022 VA hip and thigh conditions examination, the Veteran reported that the claimed hip condition began gradually in 2002. He had pain in his lower back that traveled down his hips into the thighs, which he treated with Motrin. On examination, both hips showed normal range of motion, including repetitive-use testing with at least three repetitions, without evidence of localized tenderness of pain on palpation. There was also no evidence of muscle atrophy, ankylosis, femur or flail hip joint impairment, or surgical history of either hip. The examiner concluded that there was no left hip or right hip diagnosis because there were no findings, signs, or symptoms to support a diagnosis in either hip. The examiner noted that the bilateral hip symptoms that the Veteran referenced were due to referred lumbar pain with radiculopathy, and there was no musculoskeletal hip issue on full review and examination. In a July 2022 VA hip and thigh conditions examination, conducted by the same examiner as the January 2022 VA examination, the Veteran reported that his claimed hip condition was due to an MVA. He had pain in his lower back that traveled down into his thighs, and a tingling and burning sensation in the thighs. He had not been treated for the condition. On examination, both hips showed reduced flexion, extension, and abduction, and normal adduction, external rotation, and internal rotation, without evidence of localized tenderness of pain on palpation. There was no evidence of muscle atrophy, ankylosis, femur or flail hip joint impairment, or surgical history of either hip. The examiner concluded that there was no diagnosis of a left hip condition or right hip condition because there were no findings, signs, or symptoms to support a diagnosis. The Veteran's symptoms were due to referred lumbar pain, and there was no objective musculoskeletal hip condition. In August 2022, the Veteran requested an MRI of his back, hips, legs, and feet due to constant pain. Results showed mild degenerative disc disease at L4-5 level and bilateral polyneuropathy, and are silent for findings of any hip condition. The Board finds the VA examiner's findings to be probative. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The conclusion that the Veteran did not have diagnoses of any left hip condition or right hip condition was rendered after reviewing the Veteran's STRs and other medical records, soliciting a medical history from the Veteran, and physical examination of the Veteran including clinical testing. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). The VA examiner provided facts and rationale on which her conclusion was based, and neither the Veteran nor his representative has produced medical records or a medical opinion to contradict the conclusion of the VA examiner. To the extent to which the hip pain was noted to be referred pain from the lumbar spine, the Board notes that claims for the lumbar spine and radiculopathy are being remanded for further development. Although the Veteran can describe observable symptoms, his statements cannot be used to determine whether he has a left or right hip diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). There is no evidence that the Veteran has the medical education and training required to make competent clinical diagnosis, or to attribute such a diagnosis to specific events or injuries. As such, the Board finds the Veteran's statements have little probative value with regard to establishing service connection. In any case, their probative value is outweighed by the probative value assigned to an evaluation conducted by a person who has medical expertise and training. In sum, the Board finds that the Veteran does not have a left hip condition or a right hip condition. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Without competent evidence of a diagnosis relevant to the claimed condition, service connection cannot be awarded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("In the absence of proof of a present disability, there can be no valid claim."); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (holding that service connection requires a showing of current disability). There is no benefit of the doubt to resolve in the Veteran's favor. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). 5. Service connection for hypertension. The Veteran contends that he went to his primary care doctor and his "blood was elevated"; however, he does not monitor his blood pressure or take any medications. See the November 2023 VA hypertension examination report. STRs are silent for mention of any complaints, diagnosis, or treatment of hypertension. Post-service VA treatment records indicate that in March 2006, the Veteran was seen by a cardiologist on referral from a VA ER for evaluation of frequent PVCs and risk stratification for proposed orthopedic surgery. He was diagnosed with cardiomyopathy, without mention of hypertension, and put on lisinopril and metoprolol. In a follow-up appointment in April 2006, the Veteran was again noted to have cardiomyopathy and his lisinopril and metoprolol were increased. The Veteran was first noted to have hypertension in a December 2006 treatment record, which was noted to be "well controlled." In April 2007, the Veteran reported that he was not taking his lisinopril. In a June 2007 VA cardiology appointment, the Veteran was seen by VA cardiology for "questionable hypertension." The treatment record notes a diagnosis of cardiomyopathy, but is silent for confirmation of a diagnosis of hypertension. In January 2008, the Veteran was again noted to have "?HTN." In November 2008 and February 2009 VA optometry appointments, the Veteran denied having a history of hypertension. In an August 2015 VA telephone appointment, the Veteran reported a normal blood pressure and no medication for hypertension. He stated that he would watch his low salt diet and exercise, and had no concerns. In a March 2018 VA neuropsychology consult, the Veteran was noted to have a history of hypertension, but he denied having it. The treating neuropsychologist noted that other than an instance of elevated blood pressure in January 2018, all previous recordings from 2005 to 2016 showed a blood pressure within normal range and there was no documentation of prescriptions for blood pressure medications. In a November 2023 VA hypertension examination, the Veteran reported that he had been told his "blood was elevated," but that he had not been diagnosed with hypertension, did not monitor his blood pressure, and did not take any medication for hypertension. Three blood pressure readings taken in the examination were 142/82, 142/78, and 146/78. The examiner concluded that the Veteran did not have enough current information in medical records or the examination to meet he diagnostic criteria for hypertension. The Board finds the VA examiner's findings to be probative. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The conclusion that the Veteran did not have a diagnosis of hypertension was rendered after reviewing the Veteran's STRs and other medical records, soliciting a medical history from the Veteran, and physical examination of the Veteran including clinical testing. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for assessing the probative value of a medical opinion include the examiner's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion). The VA examiner provided the rationale on which her conclusion was based, and neither the Veteran nor his representative has produced medical records or a medical opinion to contradict the conclusion of the VA examiner. Although the Veteran can describe observable symptoms, his statements cannot be used to determine whether he has hypertension. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). There is no evidence that the Veteran has the medical education and training required to make competent clinical diagnosis, or to attribute such a diagnosis to specific events or injuries. As such, the Board finds the Veteran's statements have little probative value with regard to establishing service connection. In any case, their probative value is outweighed by the probative value assigned to an evaluation conducted by a person who has medical expertise and training. In sum, the Board finds that the Veteran does not have a diagnosis of hypertension. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). Without competent evidence of a diagnosis relevant to the claimed condition, service connection cannot be awarded. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("In the absence of proof of a present disability, there can be no valid claim."); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004) (holding that service connection requires a showing of current disability). There is no benefit of the doubt to resolve in the Veteran's favor. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Earlier Effective Date In general, the effective date of an award of disability compensation, in conjunction with a grant of entitlement to service connection, shall be the day following separation from active service or the date entitlement arose if the claim is received within one year of separation from service; otherwise, the effective date shall 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(b)(2)(i). The law grants a period of one year from the date of the notice of the result of the initial determination for initiating an appeal by filing a notice of disagreement; otherwise, that determination becomes final and is not subject to the revision on the same factual basis in the absence of clear and unmistakable error (CUE). 38 U.S.C. § 7105; 38 C.F.R. § 3.105(a). An effective date for a claim for increase may be granted prior to the date of claim if it is factually ascertainable that an increase in disability had occurred within one year from the date of claim. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(1) and (2). Thus, according to Harper v. Brown, 10 Vet. App. 125, 126 (1997), three possible effective dates may be assigned depending on the facts of the particular case: (1) if an increase in disability occurs after the claim is filed, the date that the increase is shown to have occurred (date entitlement arose) (38 C.F.R. § 3.400(o)(1)); (2) if an increase in disability precedes the claim by a year or less, the date that the increase is shown to have occurred (i.e., the date the increase is factually ascertainable) (38 C.F.R. § 3.400(o)(2)); or (3) if an increase in disability precedes the claim by more than a year, the date that the claim is received (date of claim) (38 C.F.R. § 3.400(o)(2)). 10. Earlier effective date for the award of service connection for migraine/headaches. The Veteran submitted an Intent to File on November 23, 2021, and submitted a claim for service connection for headaches in December 2021. Service connection for migraine/headaches was granted in a February 2022 rating decision, with a 30 percent rating assigned effective November 23, 2021. The Veteran contends that an effective date of October 26, 2021, for service connection is warranted, which is the date VA received an Intent to File. See the July 2023 Higher Level Review brief. The Board agrees and finds that an effective date of October 26, 2021, is warranted for the award of service connection for migraine/headaches. An effective date earlier than October 26, 2021, for the award of service connection for migraine/headaches is not warranted. See 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(q) and (r). The Board has reviewed the record to determine whether any claim of service connection for headaches was filed prior to October 26, 2021, but finds that there is no such document in the claims file. See 38 C.F.R. §§ 3.151, 3.155; Rudd v. Nicholson, 20 Vet. App. 296 (2006) (holding that a freestanding claim for effective date earlier than the date on which the claim was received, impermissibly attempts to vitiate the rule of finality). Even if a December 2018 claim for service connection for a head injury is considered to have implicitly included a claim for service connection for headaches, the Veteran was notified in January 2019 that he did not file the claim on the correct form. A correct form was included in the notification, and the Veteran was informed that if an application was received within one year of the December 2018 claim, VA would consider the claim filed as of the December 2018 claim. No claim for service connection was received within a year. Accordingly, under the applicable regulations, October 26, 2021, the date that the Intent to File was received, is the earliest assignable date for the award of service connection for migraine/headaches. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. In reaching this conclusion, the benefit of the doubt has been considered; however, the evidence supports a finding that an earlier effective date for service connection is not warranted. As such, there is no benefit of the doubt to resolve in the Veteran's favor. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). 11. Earlier effective date for the assignment of a 70 percent rating for PTSD. Service connection for PTSD was granted in an August 2020 rating decision, with an initial 30 percent rating assigned under Diagnostic Code 9411 effective March 26, 2020. The Veteran did not appeal the issue. On October 26, 2021, the Veteran filed an Intent to File and also a claim for an increased rating for PTSD. In December 2021, the rating was increased to 50 percent effective October 26, 2021. In March 2022, less than one year later, the Veteran submitted an Intent to File and a Supplemental Claim requesting an increased rating and earlier effective date for PTSD. In September 2022, the 50 percent rating effective October 26, 2021, was continued. In July 2023, the Veteran requested higher-level review of the rating and effective date for PTSD. In a July 2023 rating decision, the RO increased the rating to 70 percent effective October 26, 2021. In February 2024, the Veteran submitted a notice of disagreement (VA Form 10182) requesting direct review of the effective date assigned in the July 2023 rating decision. The Board has reviewed the record to determine whether any formal or informal claim for an increased rating for PTSD was filed prior to October 26, 2021, that was not adjudicated in the August 2020 rating decision, but finds that there is no such document in the claims file. See 38 C.F.R. §§ 3.151, 3.155; Rudd v. Nicholson, 20 Vet. App. 296 (2006) (holding that a freestanding claim for effective date earlier than the date on which the claim was received, impermissibly attempts to vitiate the rule of finality). The Veteran's attorney asserts that the 70 percent rating is warranted from October 26, 2020, which is one year prior to the date that the October 26, 2021, Intent to File was received. See the July 2023 Higher Level Review brief. As noted above, an effective date for a claim for increase may be granted prior to the date of claim if it is factually ascertainable that an increase in disability had occurred within one year from the date of claim. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(1) and (2). In support of his contention, the Veteran's attorney cites a VA treatment record dated in September 2021, which notes that the Veteran had just reestablished care and medication, and had not been treated since 2018. His symptoms included depression, irritability, avoiding crowds and isolating, easily startled, chronic insomnia, and inability to focus. The attorney also noted a March 2022 statement from the Veteran describing his PTSD symptoms to include chronic suicidal ideations, obsessional rituals, low tolerance for people, anger issues, and loss of job due to these symptoms. Under Diagnostic Code 9411, a 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. The Board finds that it is not factually ascertainable that the Veteran's PTSD symptoms worsened within one year prior to the October 26, 2021, Intent to File. The September 2021 VA treatment record does not show a worsening of symptoms; rather, the reported symptoms of depression, irritability, avoiding crowds and isolating, easily startled, chronic insomnia, and inability to focus are consistent with the findings of an August 2020 VA PTSD examination, which was used as medical evidence in the August 2020 rating decision that assigned an initial 30 percent evaluation for PTSD. In the August 2020 VA examination, the Veteran reported symptoms of moderate depression, withdrawn and socially avoidant, and impaired sleep. He also reported having mild problems with memory and taking time off work regularly when feeling stressed. With regard to the March 2022 statement, the Board acknowledges that the statement indicates a worsening of the Veteran's symptoms, including contemplation of suicide and "recently" losing his job due to physical and psychiatric problems. However, the statement does not contain any indication that the symptoms worsened within the one year prior to October 26, 2021. In sum, the Board finds that an effective date prior to October 26, 2021, is not warranted. In reaching this conclusion, the benefit of the doubt has been considered; however, the evidence supports a finding that an earlier effective date for the 70 percent rating for PTSD is not warranted. As such, there is no benefit of the doubt to resolve in the Veteran's favor. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). 12. Earlier effective date for the assignment of a 20 percent rating for right shoulder separation. 13. Earlier effective date for the assignment of a 10 percent rating for right elbow strain. Service connection for right shoulder separation and irregularity of right elbow radial head, both status post MVA, were granted in a March 2005 rating decision. An initial 10 percent rating was assigned for the right shoulder and an initial noncompensable (zero percent) rating was assigned for the right elbow, both effective March 15, 2005. The Veteran did not appeal the right elbow issue; however, in January 2006, less than a year after the March 2005 rating decision, he requested an increased rating for the right shoulder. In a June 2006 rating decision, the 10 percent rating for the right shoulder was continued. The Veteran did not appeal the issue. In December 2018, the Veteran filed a Supplemental Claim for Compensation (VA Form 21-526b) requesting increased ratings for the right shoulder and right elbow disabilities. However, in January 2019, VA notified the Veteran that his application was incomplete and that it could not be processed until he returned an updated VA Form 526EZ, which was enclosed. If the application was received within one year from the date of the December 2018 incomplete application, the claim date would be the date of the December 2018 claim. No claim was received within a year. On October 26, 2021, the Veteran filed an Intent to File and also a claim for increased ratings for the right shoulder and the right elbow. In December 2021, the rating for the right shoulder was increased to 20 percent and the rating for the right elbow was increased to 10 percent, both effective October 26, 2021. In March 2022, less than one year later, the Veteran submitted an Intent to File and a Supplemental Claim requesting earlier effective dates for the right shoulder and right elbow. In a September 2022 rating decision, effective dates earlier than October 26, 2021, for the evaluation of the right shoulder and right elbow disabilities were denied. In July 2023, the Veteran requested higher-level review of the effective dates for the right shoulder and right elbow. In a July 2023 rating decision, the RO denied earlier effective dates for the increased ratings. In February 2024, the Veteran submitted a notice of disagreement (VA Form 10182) requesting direct review of the October 26, 2021, effective dates assigned to the right shoulder and right elbow disabilities. The Board has reviewed the record to determine whether any formal or informal claim for an increased rating for the right shoulder or right elbow was filed prior to October 26, 2021, that was not adjudicated in the March 2005 and June 2006 rating decisions, but finds that there is no such document in the claims file. See 38 C.F.R. §§ 3.151, 3.155; Rudd v. Nicholson, 20 Vet. App. 296 (2006) (holding that a freestanding claim for effective date earlier than the date on which the claim was received, impermissibly attempts to vitiate the rule of finality). The Veteran's attorney asserts that the increased 20 percent rating for the right shoulder and the 10 percent rating for the right elbow are warranted from October 26, 2020, which is one year prior to the date that the October 26, 2021, Intent to File was received. See the July 2023 Higher Level Review brief. The Board finds that it is not factually ascertainable that the right shoulder or right elbow disability worsened within one year prior to the October 26, 2021, Intent to File. VA treatment records during the period between October 26, 2020, and October 25, 2021, indicate that the Veteran had a history of a right shoulder and elbow injury, but are silent for mention of any current complaints or treatment of the right shoulder or right elbow. In sum, the Board finds that an effective date prior to October 26, 2021, is not warranted for the increased rating for the right shoulder the right elbow. In reaching these conclusions, the benefit of the doubt has been considered; however, the evidence supports a finding that an earlier effective date for the 20 percent rating for the right shoulder and an earlier effective date for the 10 percent rating for the right elbow is not warranted. As such, there is no benefit of the doubt to resolve in the Veteran's favor. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). 14. Earlier effective date for the award of a separate rating for right knee instability, associated with right knee osteoarthritis. 15. Earlier effective date for the award of a separate rating for right knee limitation of extension, associated with right knee osteoarthritis. Service connection for right knee retropatellar pain, status post non-displaced lateral femoral condyle fracture, was granted in a March 2005 rating decision, with an initial 10 percent rating assigned under Diagnostic Code 5099-5262 effective March 15, 2005. The hyphenated diagnostic code indicates that an unlisted disability of the musculoskeletal system (Diagnostic Code 5099) is rated under the criteria for malunion of the tibia and fibula (Diagnostic Code 5262). Prior to February 7, 2021, Diagnostic Code 5262 provided a 10 percent rating for malunion of the tibia and fibula with slight knee or ankle disability. In January 2006, less than a year after the March 2005 rating decision, the Veteran requested an increased rating for the right knee. In a June 2006 rating decision, the 10 percent rating for the right knee was continued. The Veteran did not appeal the issue. In December 2018, the Veteran filed a Supplemental Claim for Compensation (VA Form 21-526b) requesting an increased rating for the right knee. However, in January 2019, VA notified the Veteran that his application was incomplete and that it could not be processed until he returned an updated VA Form 526EZ, which was enclosed. If the application was received within one year from the date of the December 2018 incomplete application, the claim date would be the date of the December 2018 claim. No claim was received within a year. On October 26, 2021, the Veteran filed an Intent to File and also a claim for an increased rating for the right knee. In December 2021, the right knee disability was recharacterized to right knee osteoarthritis, and the 10 percent rating was continued under Diagnostic Code 5010-5260, indicating that traumatic arthritis (Diagnostic Code 5010) is rated under the criteria for malunion of the tibia and fibula (Diagnostic Code 5262). In March 2022, less than one year later, the Veteran submitted an Intent to File and a Supplemental Claim requesting an increased rating for the right knee. He also submitted an Application for Disability Compensation and Related Compensation Benefits in June 2022. In August and September 2022 rating decisions, the 10 percent rating for right knee osteoarthritis was continued. On September 19, 2022, the Veteran submitted an Application for Disability Compensation and Related Compensation Benefits requesting an increased rating for the right knee. In an October 2022 rating decision, the 10 percent rating for right knee osteoarthritis was continued, and two additional 10 percent ratings for the right knee were granted. A 10 percent rating for right knee instability was granted under Diagnostic Code 5257, and a 10 percent rating for right knee limitation of extension was granted under Diagnostic Code 5261, both effective September 19, 2022. Diagnostic Code 5257 evaluates other impairment of the knee, to include recurrent subluxation or instability and patellar instability. For recurrent subluxation or instability, a 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For patellar instability, a 10 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (from February 7, 2021). Diagnostic Code 5261 provides a 10 percent rating for extension limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5261. In July 2023, the Veteran requested higher-level review of the effective dates for the right knee ratings. In a July 2023 rating decision, the RO determined that a clear and unmistakable error (CUE) was made, and an effective date of September 12, 2022, was warranted for the right knee instability and right knee limitation of extension ratings. In February 2024, the Veteran submitted a notice of disagreement (VA Form 10182) requesting direct review of the effective dates assigned to the right knee instability and limitation of extension ratings. The Board has reviewed the record to determine whether any formal or informal claim for an increased rating for the right knee was filed prior to October 26, 2021, that was not adjudicated in the March 2005 or June 2006 rating decisions, but finds that there is no such document in the claims file. See 38 C.F.R. §§ 3.151, 3.155; Rudd v. Nicholson, 20 Vet. App. 296 (2006) (holding that a freestanding claim for effective date earlier than the date on which the claim was received, impermissibly attempts to vitiate the rule of finality). The Veteran's attorney asserts that the right knee instability and limitation of extension ratings should be effective no later than October 26, 2021, which is one year prior to the Veteran's increased rating claim. See the July 2023 Higher Level Review brief. (The Board notes that the attorney presumably meant to assert that an effective date no later than October 26, 2020, is warranted.) As discussed above, the effective date for an increased rating is the date of receipt of the claim or the date entitlement arose, whichever is later. Here, the Board agrees with the Veteran's attorney that the Veteran's increased rating claim was received on October 26, 2021. However, in November 2021 and July 2022 VA knee conditions examinations, the Veteran's right knee active and passive range of motion measurements included extension to zero degrees. After repetitive-use testing with at least three repetitions, there was no additional loss of function or range of motion. There was no finding of recurrent subluxation, persistent instability, or recurrent patellar instability. The Board finds that the October 2022 VA knee examination report is the earliest evidence showing a factually ascertainable increase in symptoms for the right knee. Specifically, this examination report shows that right knee extension was limited to 10 degrees after repeated use over time and/or during flare-ups; and indicates that there was recurrent subluxation or persistent instability. There was no finding of recurrent patellar instability, and the Veteran did not use any assistive devices. As such, this examination report is the earliest evidence showing that a 10 percent rating is warranted under Diagnostic Code 5257 for persistent instability without a prescription from a medical provider for an assistive device, and a 10 percent rating is warranted under Diagnostic Code 5261 for extension limited to 10 degrees. See 38 C.F.R. § 4.71a, Diagnostic Codes 5257 and 5261. In sum, there is no medical evidence that 10 percent ratings are warranted for right knee instability or limitation of extension prior to the October 2022 VA knee examination. The Board will not, however, disturb the earlier September 12, 2022, effective dates already assigned, as they are more favorable to the Veteran. Accordingly, entitlement to an effective date earlier than September 12, 2022, for the 10 percent ratings for right knee instability and right knee limitation of extension is not warranted. In reaching this conclusion, the benefit of the doubt has been considered; however, the evidence supports a finding that an earlier effective date for the two 10 percent ratings is not warranted. As such, there is no benefit of the doubt to resolve in the Veteran's favor. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Increased Rating Disability evaluations are 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 the residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. 16. Increased rating for hiatal hernia, to include an earlier effective date. The Veteran has been assigned a noncompensable (zero percent) rating for hiatal hernia under Diagnostic Code 7346 for the entire period of appeal (from October 26, 2021). Under Diagnostic Code 7346, a 60 percent rating is warranted for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. (Material weight loss is not defined in Diagnostic Code 7346, but "substantial weight loss" is defined under 38 C.F.R. § 4.112 as a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer, and "minor weight loss" is defined as a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer under.) 38 C.F.R. § 4.114, Diagnostic Code 7346. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. The Board notes that the criteria for rating digestive disabilities were amended, effective May 19, 2024. These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or after May 19, 2024. However, because the Veteran's claim for an increased rating for GERD was filed before May 19, 2024, and the appeal period before the Board is also prior to May 19, 2024, the new rating criteria are not for application. The Veteran contends without further elaboration that an increased rating is warranted. The Board finds that a compensable rating is not warranted at any point during the period of appeal. In a November 2021 VA esophageal conditions examination, the Veteran reported that his hiatal hernia was asymptomatic and had heartburn with certain foods sometimes. He used omeprazole "as needed only." The examiner indicated that the Veteran's only symptom was pyrosis (heartburn). There were no symptoms of infrequent episodes or persistently recurrent epigastric distress, dysphagia, reflux, regurgitation, substernal or arm pain, sleep disturbance caused by esophageal reflux, material weight loss, nausea, vomiting, hematemesis, or melena with moderate anemia, and the symptoms were not productive of considerable impairment of health or severe impairment of health. The Veteran did not have an esophageal stricture, spasm of the esophagus, or an acquired diverticulum of the esophagus. There were no other pertinent physical findings, complications, conditions, signs, or symptoms related to the hiatal hernia. VA treatment records indicate that in June 2022, the Veteran reported having reflux, and denied having any abdominal pain, melena, or fresh blood in stool. He was prescribed pantoprazole to take once per day before breakfast for stomach/acid reflux. In sum, the Board finds that the Veteran's hiatal hernia does not more nearly approximate the level of severity contemplated by an increased 10 percent rating. Under Diagnostic Code 7346, a 10 percent rating is warranted for a hiatal hernia with two or more of the symptoms for the 30 percent evaluation of less severity. A 30 percent rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Here, the Veteran's sole symptom of the hiatal hernia is pyrosis. The Veteran himself noted in the November 2021 VA examination that the hernia was asymptomatic other than heartburn with certain foods. As such, an increased 10 percent rating is not warranted under Diagnostic Code 7346. The Board has considered whether there is any other schedular basis for granting a higher rating other than that discussed above, but has found none. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). In this regard, the Board notes that Diagnostic Codes 7200 through 7357 refer to ratings for the digestive system. The Veteran has not been shown to have any relevant symptoms other than heartburn. Other diagnostic codes are therefore not applicable. Finally, the Board acknowledges that the Veteran also appealed the issue of an earlier effective date. As noted above, an effective date for a claim for increase may be granted prior to the date of claim if it is factually ascertainable that an increase in disability had occurred within one year from the date of claim. 38 U.S.C. § 5110(b)(2); 38 C.F.R. § 3.400(o)(1) and (2). However, because the rating for the hiatal hernia has not been increased, entitlement to an earlier effective date is not warranted. See Rudd v. Nicholson, 20 Vet. App. 296 (2006). REASONS FOR REMAND 1. Entitlement to service connection for lumbar strain is remanded. The Veteran contends that the claimed back condition is related to the service-connected bilateral knee disabilities. See the July 2023 Higher Level Review brief. In a February 2022 VA back conditions examination, the Veteran was diagnosed with lumbosacral strain, which the examiner opined was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because the Veteran had an acute in-service back injury and there was no chronicity of care. In a July 2022 VA back conditions examination, the Veteran was again diagnosed with lumbosacral strain. No opinion was provided on the etiology of the diagnosis. In November 2023, the Veteran had a third VA back conditions examination, in which he was diagnosed with lumbosacral strain, intervertebral disc syndrome (IVDS), and bilateral lower extremity radiculopathy involving the sciatic nerve. The examiner opined that the back condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because there was no chronicity of care. The Veteran reported back pain in service in 2004 after an MVA, and was next seen in 2015. None of the VA examiners opined on whether the service-connected knee disabilities caused or aggravated the claimed back condition. The Board cannot substitute its medical judgment for that of a qualified medical professional. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board therefore finds a pre-decisional error in not obtaining an adequate medical opinion on the nature and etiology of the claimed lumbar strain. 38 C.F.R. § 3.159(c). 2. Entitlement to service connection for left lower extremity radiculopathy/sciatica is remanded. 3. Entitlement to service connection for right lower extremity radiculopathy/sciatica is remanded. In November 2023, after a VA back conditions examination, a VA examiner opined that the claimed bilateral lower extremity radiculopathy was at least as likely as not proximately due to or the result of the lumbar strain. The claims for service connection for bilateral lower extremity radiculopathy/sciatica are therefore inextricably intertwined with the claim for service connection for lumbar strain being remanded herein, and the Board will remand the radiculopathy/sciatica claims to adjudication them at the same time as the lumbar strain claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991). 4. Entitlement to service connection for cardiomyopathy with ventricular arrhythmias is remanded. The Veteran contends that his service-connected disabilities caused him to become obese, which caused or aggravated the claimed heart condition. See the July 2023 Higher Level Review brief. In a December 2021 VA heart conditions examination, the Veteran was noted to have diagnoses of ventricular arrhythmia and cardiomyopathy. In November 2023, a VA examiner reviewed the Veteran's file and opined that the claimed condition was less likely than not cause by the indicated toxic exposure risk activity(ies) (TERA), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner did not opine on whether the Veteran's contention that his service-connected disabilities caused him to gain weight, which caused or aggravated the claimed heart condition. The Board cannot substitute its medical judgment for that of a qualified medical professional. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board therefore finds a pre-decisional error in not obtaining an adequate medical opinion on the nature and etiology of the claimed heart condition. 38 C.F.R. § 3.159(c). 5. Entitlement to service connection for OSA is remanded. The Veteran contends that his service-connected PTSD caused or aggravated the claimed OSA, to include as due to alcohol abuse, which is due to PTSD. The Veteran alternatively contends that his service-connected disabilities caused him to gain weight, which caused or aggravated the claimed OSA. See the July 2023 Higher Level Review brief. The Veteran had VA sleep apnea examinations in September and December 2021 in which he was noted to have a diagnosis of OSA. A series of VA medical opinions were obtained on the nature and etiology of the diagnosed OSA between September 2021 and August 2023. In September 2021, a VA examiner opined that the OSA was unrelated to the Veteran's service in Southwest Asia, noting that sleep apnea is a sleep disorder in which breathing repeatedly stops and starts, which occurs when throat muscles relax. With obesity, during sleep, when throat and tongue muscles are more relaxed, this soft tissue can cause the airway to become blocked. In October 2021, a VA examiner opined that the OSA was less likely than not proximately due to or the result of the service-connected PTSD. The examiner noted that obesity is a well-established risk factor for OSA and that although there had been studies showing an association between PTSD and OSA, there was no causal pathologic relationship. In December 2021, a VA examiner opined that the OSA was less likely than not proximately due to or aggravated by the service-connected right knee, left knee, hernia, right shoulder, right elbow, tinnitus, pes planus/plantar fasciitis, and/or obesity because medical literature failed to demonstrate a causal or secondary relationship. The examiner noted that although there were increased incidences of OSA among people who are overweight, that did not equal a causal relationship. The Veteran also had other risk factors, including a history of alcohol abuse and smoking tobacco. In August 2022, a VA examiner opined that the OSA was less likely than not proximately due to or the result of the service-connected PTSD because "PTSD does not represent an established primary etiology of sleep apnea in the medical literature." Finally, in August 2023, a VA examiner again opined that that the OSA was less likely than not proximately due to or the result of the service-connected PTSD because they are two separate entities. The examiner also opined that the OSA was less likely than not caused by the indicated TERA. The examiner noted that the Veteran had a diagnosis of obesity at the time of the OSA diagnosis, and that his multiple orthopedic concerns likely contributed to his lack of participation in physical activity. Furthermore, his non-compliance with a CPAP machine and making poor food choices also contributed to obesity. The examiner also opined, however, that the Veteran's obesity existed in service and preexisted the OSA diagnosis, and there was no evidence of permanent aggravation beyond normal progression. The Board finds that these VA opinions are not sufficient bases on which to adjudicate the claim for service connection for OSA. The September and October 2021 opinions imply that obesity is causally related to the Veteran's OSA, but do not contain an express opinion on the issue. The December 2021 opinion implies that alcohol abuse is related to the OSA, which the Veteran asserts is due to his service-connected PTSD, but does not contain an opinion on the issue. See a November 19, 2021, VA treatment record cited by the Veteran's attorney in the July 2023 Higher Level Review brief, in which the Veteran is noted to have various mental health diagnoses including PTSD and alcohol abuse. The August 2022 opinion does not consider whether alcohol abuse is related to the OSA. The August 2023 opinion is not internally consistent, as the examiner implied that obesity was a cause of the OSA, and that the Veteran's musculoskeletal concerns contributed to his lack of participation in physical activity; but that the obesity did not aggravate the OSA beyond the normal progression. It is also unclear to the Board whether the August 2023 examiner's opinion on aggravation was regarding whether the OSA was aggravated by obesity, or whether the obesity was aggravated by service. The Board cannot substitute its medical judgment for that of a qualified medical professional. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board therefore finds a pre-decisional error in not obtaining an adequate medical opinion on the nature and etiology of the claimed OSA. 38 C.F.R. § 3.159(c). 6. Entitlement to service connection for erectile dysfunction is remanded. The Veteran contends that the claimed erectile dysfunction is due to the service-connected PTSD. See the July 2023 Higher Level Review brief. In a November 2023 VA male reproductive organ conditions examination, the Veteran was diagnosed with erectile dysfunction. The examiner opined that the condition was less likely than not caused by the indicated TERA. The VA examiner did not opine on whether the service-connected PTSD caused or aggravated the condition. The Board cannot substitute its medical judgment for that of a qualified medical professional. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board therefore finds a pre-decisional error in not obtaining an adequate medical opinion on the nature and etiology of the claimed erectile dysfunction. 38 C.F.R. § 3.159(c). The matters are REMANDED for the following action: 1. Obtain a VA medical opinion on the nature and likely etiology of the claimed lumbar strain. After reviewing the entire record, the examiner should opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any diagnosed back condition was either (i) caused by, or (ii) aggravated (chronically worsened) by the Veteran's service-connected bilateral knee disabilities? A thorough rationale should be provided for all opinions expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the AOJ should schedule the Veteran for such an examination. 2. Obtain a VA medical opinion on the nature and likely etiology of the claimed heart condition, diagnosed as cardiomyopathy and ventricular arrhythmias. After reviewing the entire record, the examiner should provide an opinion in answer to the following questions: i) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any of the Veteran's service-connected disabilities caused him to become obese? ii) If the answer to i) is yes, is it at least as likely as not that the Veteran's obesity as a result of the service-connected disabilities was a substantial factor in causing the heart condition(s)? iii) If the answer to ii) is yes, is it at least as likely as not that the heart condition(s) would not have occurred but for obesity caused by the service-connected disabilities? iv) If the answer to i) through iii) is no, then is it at least as likely as not that the heart condition(s) was aggravated (chronically worsened) by the service-connected disabilities? A thorough rationale should be provided for all opinions expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. If the VA examiner determines that further examination is necessary in order to render the requested medical opinions, the AOJ should schedule the Veteran for such an examination. 3. Obtain a VA medical opinion on the nature and likely etiology of the diagnosed obstructive sleep apnea (OSA). After reviewing the entire record, the examiner should provide an opinion in answer to the following questions: i) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the OSA was either (i) caused by, or (ii) aggravated (chronically worsened) by the Veteran's service-connected PTSD, to include consideration of whether the PTSD caused alcohol abuse, which in turn caused or aggravated the OSA? ii) Is it at least as likely as not that any of the Veteran's service-connected disabilities caused him to become obese? iii) If the answer to ii) is yes, is it at least as likely as not that the Veteran's obesity as a result of the service-connected disabilities was a substantial factor in causing the OSA? iv) If the answer to iii) is yes, is it at least as likely as not that the OSA would not have occurred but for obesity caused by the service-connected disabilities? v) If the answer to ii) through iv) is no, then is it at least as likely as not that the OSA was aggravated by the service-connected disabilities? A thorough rationale should be provided for all opinions expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. If the VA examiner determines that further examination is necessary in order to render the requested medical opinions, the AOJ should schedule the Veteran for such an examination. 4. Obtain a VA medical opinion on the nature and likely etiology of the diagnosed erectile dysfunction. After reviewing the entire record, the examiner should opine on whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the erectile dysfunction was either (i) caused by, or (ii) aggravated (chronically worsened) by the Veteran's service-connected PTSD? A thorough rationale should be provided for all opinions expressed. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the AOJ should schedule the Veteran for such an examination. H. SEESEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Nelson 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.