Citation Nr: A25035463 Decision Date: 04/17/25 Archive Date: 04/17/25 DOCKET NO. 230216-325551 DATE: April 17, 2025 REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for headache disability is remanded. Entitlement to service connection for skin disability, claimed as rash or skin condition, is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from September 1968 to January 1970. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO), the Agency of Original Jurisdiction (AOJ), in November 2022 and January 2023. In the February 2023 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the AOJ rating decisions that adjudicated the specific corresponding issue as identified in the February 2023 Notice of Disagreement. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. Relevantly, the Board notes that the Appeals Modernization Act (AMA) has previously been understood to be a linear appeal system, meaning that a request for review - such as a supplemental claim, request for higher-level review, or Board appeal - could only be filed with respect to the most recent adjudicative decision. However, in Terry v. McDonough, 37 Vet. App. 1 (2023), the United States Court of Appeals for the Federal Circuit (Court) held that multiple administrative reviews can be filed as to one AOJ decision, so long as they are within one year of notice of that decision and not otherwise precluded by statute or regulation. Notwithstanding the holding in Terry, a Veteran is still precluded from seeking concurrent administrative review of the same issue. Here, the Veteran identified two rating decisions in the February 2023 Notice of Disagreement - issued in November 2022 and January 2023 - that he wished to appeal regarding the issue of entitlement to service connection for obstructive sleep apnea. As discussed above, this type of concurrent election would normally be precluded under Terry. However, the Veteran filed only one Notice of Disagreement for his claim for service-connected obstructive sleep apnea. Given that any subsequent filing would be untimely as to any rating decision of record on this issue, the Board determines that the January 2023 rating decision is the appropriate decision on appeal. The Board further notes that this is the most favorable outcome for the Veteran because it provides the largest evidentiary consideration window allowable under the AMA. Regardless, because the Board is remanding all issues currently on appeal, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii). 1. Entitlement to service connection for obstructive sleep apnea. The Veteran asserts that his current sleep apnea disability is directly related to military service or, alternatively, is secondary to his service-connected PTSD. Upon review of the record, the Board finds that the Veteran's claim for service-connected sleep apnea must be remanded to allow the AOJ to correct a duty-to-assist error that occurred prior to the issuance of January 2023 rating decision on appeal. At the outset, the Board notes the AOJ issued the following relevant favorable findings in the January 2023 rating decision on appeal: "You have been diagnosed with a disability. VAMC treatment record dated July 31, 2018 showed your portable sleep study indicated moderate sleep apnea;" and "The claimed primary disability is service-connected. You have been service connected for posttraumatic stress disorder, with alcohol, cocaine and cannabis use disorder in sustained remission, since March 1, 2021." Rating Decision - Narrative, dated January 25, 2023. Under the AMA, the Board is bound by favorable findings unless they are rebutted by clear and unmistakable evidence. 38?C.F.R. §§?3.104(c); 20.801(a). After a thorough review of the Veteran's electronic claim file, the Board concludes that such clear and unmistakable evidence does not exist. As to the other elements of direct and secondary service connection, the Board determines that remand is necessary to correct a pre-decisional duty-to-assist error in failing to provide an adequate medical examination for the Veteran's obstructive sleep apnea. In August 2021, VA medical examiner, W.R., M.D., provided the following rationale for his negative secondary nexus opinion: "No objective medical record or reputable medical literature evidence to indicate otherwise was found. There is no mechanism of action for cause or permanent aggravation beyond natural progression of the Veteran's OSA by his service connected conditions to include PTSD with alcohol, cocaine and cannabis use disorder in sustained remission or the medications used to treat such." C&P Exam, received December 15, 2022. Dr. W.R. further noted that the Veteran was diagnosed with obesity and that obesity is a risk factor - among many others - for obstructive sleep apnea. However, Dr. W.R. also provided the following note of caution regarding a nexus opinion based on obesity: "Nevertheless, it should be remembered that a risk factor is not the same as a cause. The cause of OSA is well documented in Harrison's Principles of Internal Medicine which states the following: "Apneas and hypopneas are caused by the airway being sucked closed on inspiration during sleep" and in UpToDate which states under PATHOPHYSIOLOGY the following: "OSA is characterized by recurrent, functional collapse during sleep of the velopharyngeal and/or oropharyngeal airway, causing substantially reduced or complete cessation of airflow despite ongoing breathing efforts. This leads to intermittent disturbances in gas exchange (eg, hypercapnia and hypoxemia) and fragmented sleep." Id. Dr. W.R.'s negative etiology opinion and underlying rationale are inadequate for adjudication purposes for multiple reasons. First, the Board notes that there are two components to a secondary service connection claim: causation and aggravation. However, in focusing on proximate causation, Dr. W.R. failed to consider whether the Veteran's obstructive sleep apnea was aggravated by his service-connected PTSD. In failing to offer an opinion addressing the theory of aggravation, Dr. W.R. committed a pre-decisional duty-to-assist error that requires a remand to rectify. See El-Amin v. Shinseki, 26?Vet. App.?136, 138-140 (2013) (a medical opinion regarding secondary service connection must address both causation and aggravation to be adequate).? Second, Dr. W.R.'s rationale conflicts with medical discussions provided in previous VA examination reports. Notably, in July 2021, VA psychologist, T.C., Ph.D. stated, "It is noted that, although not entirely clear why, research indicates that there is a higher prevalence of OSA among people with PTSD and PTSD symptoms can be exacerbated by sleep apnea." C&P Exam, received July 1, 2021. Dr. T.C.'s statement does not establish a definitive link between PTSD and obstructive sleep apnea; however, Dr. T.C.'s statement appears to conflict with Dr. W.R.'s assessment that there is "[n]o objective medical record or reputable medical literature evidence to indicate" that a link between obstructive sleep apnea and PTSD exists. C&P Exam, received December 15, 2022. Neither Dr. W.R. nor the AOJ attempted to reconcile the conflict described above. See Miller v. West, 11?Vet. App.?345, 348 (2007) (stating that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record); see also Bailey?v. O'Rourke, 30?Vet. App.?54, 60-61 (2018) (holding that a medical opinion was inadequate as a matter of law because the rationale was based solely on general articles and did not discuss any facts pertaining to Veteran's condition or individual circumstances). Third, Dr. W.R. provided a conclusory rationale that was devoid of facts specific to the Veteran's medical history or relevant medical evidence of record. See Stefl v. Nicholson, 21?Vet. App.?120, 124 (2007) (a medical opinion must clearly "support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Similarly, despite noting the Veteran's reported sleep-related issues, Dr. W.R.'s negative nexus opinion and underlying rationale do not discuss, or otherwise appear contemplate, the Veteran's lay statements or medical evidence of record regarding the onset, duration, and frequency of his sleep apnea-related symptomatology. See Miller v. Wilkie, 32?Vet. App.?249 (2020) (explaining that a VA examination is inadequate if the examiner does not consider lay evidence); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (finding that an examiner impermissibly ignored the appellant's lay assertions that he had sustained a back injury in service); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating, "The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion"). Finally, both the AOJ and Dr. W.R. failed to consider obesity as an intermediate step between his service-connected PTSD and his current sleep apnea disability. See DeLisio v. Shinseki, 25 Vet. App. 45, 53 (2011) (VA must "investigate the reasonably apparent and potential causes of the veteran's condition and theories of service connection that are reasonably raised by a sympathetic reading of the claim."); Kent v. Nicholson, 20 Vet. App. 1, 16 (2006) (explaining that a claim "includes all theories under which service connection may be granted"). To be sure, obesity is not recognized by VA as a disease or disability for compensation purposes but, instead, may serve as an intermediate step when considering secondary service connection under 38?C.F.R. §?3.310. See VAOPGCPREC 1-2017. However, in Walsh v. Wilkie, 32?Vet. App.?300, 307 (2020), the United States Court of Appeals for Veterans Claims (Court) held that proper interpretation of G.C. Prec. Op. 1-2017 requires consideration of both proximate causation and aggravation for obesity in its analytical framework. Here, Dr. W.R. noted that the Veteran was diagnosed with obesity by treatment providers. See C&P Exam, received December 15, 2022; see also CAPRI, received January 19, 2023. However, the Veteran's medical records show that the Veteran suffered from fluctuations in appetite, apathy, and decreased motivation to perform activities that were considered, at least in part, either a direct symptom of his PTSD or a potential side effect of his psychotropic medication regimen. See C&P Exam, received June 30, 2021 and July 1, 2021; CAPRI, pgs. 138-140, received January 19, 2023. The Board acknowledges that the AOJ did not specifically direct Dr. W.R. to address obesity as an intermediate step. Nevertheless, because it was raised - both explicitly and implicitly - by the record and because the Veteran's obesity and sedentary lifestyle could potentially be related to his service-connected PTSD, the Board finds that remand is still required for a new medical opinion that contemplates the relationship between obesity and the Veteran's obstructive sleep apnea. Ultimately, given the issues outlined above, the Board finds that an updated examination and opinion must be provided. Stegall v. West,?11?Vet. App.?268?(1998); see also Barr v. Nicholson,?21?Vet. App.?303, 311?(2007) (holding that when VA elects to provide a medical examination, the examination must be adequate).? 2. Entitlement to service connection for headache disability. The Veteran also contends that his headache disability is directly related to active-duty service, or as secondary to his service-connected PTSD. At the outset, the Board notes that the July 2023 rating decision on appeal contains the following favorable findings regarding the first and second criteria of direct and secondary service connection: "You have been diagnosed with a disability. QTC exam dated May 27, 2022 noted a diagnosis of migraine headaches;" and "The evidence shows that a qualifying event, injury, or disease had its onset during your service. Service treatment record dated January 18, 1969 showed you complained of headaches for three days. The claimed primary disability is service-connected. You are service connected for posttraumatic stress disorder with alcohol, cocaine and cannabis use disorder in sustained remission." Rating Decision - Narrative, dated November 25, 2022. Again, the Board is bound by favorable findings unless they are rebutted by clear and unmistakable evidence, which does not exist here. 38 C.F.R. §§ 3.104(c); 20.801(a). As to the remaining criteria for direct and secondary service connection, the Board determines that the AOJ erred in failing to obtain an adequate medical opinion prior to the November 2022 rating decision on appeal. In May 2022, VA medical examiner, T.H., D.O., provided negative nexus opinions for both direct and secondary service connection based on the rationale that "[t]here is only 1 mention of headaches in the records provided for review...." C&P Exam, received May 31, 2022. Dr. T.H. further noted, "There is no mention of headaches since 1969 in the records provided for review. Therefore, it does not appear as there is a nexus for the claim of headaches." Dr. T.H. also reasoned, "It would be expected that if the claimant's PTSD was the source of headaches, he would have complaint of headaches persistently over time. That is not the case." Id. The Board finds Dr. T.H.'s opinion inadequate for adjudication purposes for multiple reasons. First, in focusing on proximate causation, Dr. T.H. failed to consider whether the Veteran's headache disability was aggravated by his service-connected PTSD. See El-Amin v. Shinseki, 26?Vet. App.?136, 138-140 (2013) (a medical opinion Second, Dr. T.H.'s opinion and underlying rationale failed to discuss or meaningfully incorporation the Veteran's lay statements regarding the onset, duration, and frequency of his conceded migraine headache disability. See Miller v. Wilkie, 32?Vet. App.?249 (2020) (explaining that a VA examination is inadequate if the examiner does not consider lay evidence); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (finding that an examiner impermissibly ignored the appellant's lay assertions that he had sustained a back injury in service); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating, "The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion"). Finally, Dr. T.H.'s negative nexus opinion is conclusory and relies primarily on a negative inference from the lack of contemporaneous medical treatment records. Notably, the mere absence of evidence of post service treatment for headaches disability cannot, alone, be sufficient rationale for providing a negative nexus opinion. See Fountain v. McDonald, 27 Vet. App. 258, 272 (2015) (stating that the Board must first establish a proper foundation for drawing inferences against a claimant from an absence of documentation); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (stating that "[w]hen assessing a claim, the Board may not consider the absence of evidence as substantive negative evidence"). Given the issues outlined above, the Board finds that an updated examination and opinion must be provided for the Veteran's claim of entitlement to service connection for his headache disability. Stegall v. West,?11?Vet. App.?268?(1998); see also Barr v. Nicholson,?21?Vet. App.?303, 311?(2007) (holding that when VA elects to provide a medical examination, the examination must be adequate). 3. Entitlement to service connection for skin disability, claimed as rash or skin condition. The Veteran contends that his skin condition is directly attributable to service. Relevantly, the Board notes that the AOJ conceded that the Veteran satisfied the first and second criteria for service connection as follows: "You have been diagnosed with a disability. LHI examination dated February 26, 2021 showed examiner noted tinea versicolor is still diagnosed but quiescent;" and "The claimed issue existed prior to military service. Service treatment records show you were diagnosed with tinea versicolor at entrance to service. The claimed issue was treated during military service. Service treatment records show treatment for rashes beginning in December 1968." Rating Decision - Narrative, dated November 25, 2022. Again, the Board is bound by favorable findings unless they are rebutted by clear and unmistakable evidence, which does not exist here. 38 C.F.R. §§ 3.104(c); 20.801(a). As to the remaining criteria for service connection, the Board determines that the AOJ erred in failing to obtain an adequate medical opinion prior to the November 2022 rating decision on appeal. The sole medical opinion of record was authored by VA medical examiner, J.M., NP, who provided a negative etiology assessment as follows: "Tinea versicolor is still diagnosed but quiescent. Veteran had clear and unmistakable evidence of the preexisting tinea versicolor. There is evidence to indicate the Veteran continued to suffer from the disorder during service, which is typical of the condition. However, the progression is not beyond normal progression for this disorder. Tinea can wax and wane and spread with temperature, hormonal changes and oily skin. Antifungal creams, lotions or shampoos can help treat tinea versicolor but not cure. But even after successful treatment, skin color may remain uneven for several weeks or months." C&P Exam, received February 26, 2021. J.M.'s opinion is inadequate because she provided a cursory statement that the Veteran's tinea versicolor preexisted service without any accompanying support or discussion of how or why she came to that conclusion. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004) (holding that VA must establish by clear and unmistakable evidence that an injury or disease that manifested in service was both (1) preexisting and (2) not aggravated by service). Moreover, even if the Board presumes that J.M. is correct that the Veteran's tinea versicolor preexisted service, J.M. also provided insufficient reasons or bases as to why the Veteran's tinea versicolor was not aggravated by the service. In doing so, the Board notes that J.M. offered very little indication that she meaningfully considered the Veteran's lay statements on this topic. Based on the foregoing, the Board finds that an updated examination and opinion must be provided for the Veteran's claim of entitlement to service connection for his skin condition. Stegall v. West,?11?Vet. App.?268?(1998); see also Barr v. Nicholson,?21?Vet. App.?303, 311?(2007) (holding that when VA elects to provide a medical examination, the examination must be adequate). 4. Entitlement to service connection for erectile dysfunction. The Veteran contends that he has erectile dysfunction, which is directly attributable to service or, alternatively, secondary to his service-connected disabilities. At the outset, the Board notes that the AOJ conceded that the Veteran satisfied the first criteria for service connection as follows: "You have been diagnosed with a disability. Active Problem List, within Milwaukee VAMC Medical Record dated October 8, 2003, confirms a diagnosis of erectile dysfunction." Rating Decision - Narrative, dated November 25, 2022. Again, the Board is bound by favorable findings unless they are rebutted by clear and unmistakable evidence, which does not exist here. 38 C.F.R. §§ 3.104(c); 20.801(a). As to the other criteria for service connection, the Board determines that the AOJ committed a pre-decisional duty-to-assist error by failing to demonstrate that the Veteran was afforded due process with respect to scheduling his VA medical examination. Notably, the record does not contain a medical opinion for the Veteran's erectile dysfunction, with the AOJ noting that the Veteran failed to appear to the multiple examinations scheduled in November 2022. Indeed, the record contains an Exam Scheduling Request dated November 15, 2022, that was generated by the RO. However, this document did not contain the date, time, or location of the Veteran's VA medical examination pursuant to this request. Otherwise, the record does not contain any information that demonstrates the RO's attempt to schedule or notify the Veteran about the date, time, or location of his scheduled VA examination for his erectile dysfunction. Based on the foregoing, the Board cannot confidently conclude that the Veteran had adequate notice of the date, time, and location of his VA examination for his erectile dysfunction. This qualifies as good cause for missing any scheduled VA medical examinations during the period on review. Accordingly, the Board finds that remand is warranted to renew efforts to schedule VA medical examination for claim for service-connected erectile dysfunction to ensure compliance with VA's duty to assist. On remand, VA must follow those procedures unless it clearly confirms and documents that he has obtained a fixed address and is reachable by the usual means. 5. Entitlement to a TDIU. Where facts underlying separate claims are "intimately connected," interests of judicial economy and avoidance of piecemeal litigation require that the claims be adjudicated together. See Smith v. Gober, 236 F.3d 1370, 1373 (2001). When one of the intimately connected claims is remanded, the proper remedy is to remand the second intimately connected claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (describing intimately connected claims as "inextricably intertwined"). Here, an award of service connection for one of the herein remanded claims would result in a material shift in the complete disability picture upon which entitlement to a TDIU will be reviewed. Accordingly, the above remanded claims are intimately connected to the Veteran's claim for a TDIU and the claim for a TDIU must also be remanded. The matters are REMANDED for the following action: 1. Schedule the Veteran for a new examination with an appropriate clinician to determine the nature and likely etiology of his current obstructive sleep apnea disability. A complete history from the Veteran should be obtained and recorded. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination and this review should be acknowledged in the report. Thereafter, the examiner must respond to the following prompts: (a.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's obstructive sleep apnea has its onset in or was incurred in service. (b.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's obstructive sleep apnea was caused or aggravated by one - or any combination - of the Veteran's service-connected disabilities. (c.) Whether the Veteran's obesity was caused or aggravated by one - or any combination - of the Veteran's service-connected disabilities. (d.) If any the Veteran's service-connected conditions either caused or aggravated the Veteran's obesity, then was the Veteran's obesity a substantial factor in causing the obstructive sleep apnea? (e.) If the answers to (c) and (d) are yes, determine whether the obstructive sleep apnea would not have occurred but for the obesity. (f.) If it is determined that neither the Veteran's service-connected conditions nor his obesity secondary to a service-connected condition were the likely etiologies of the Veteran obstructive sleep apnea, then state which condition or combination of conditions at least as likely as not caused or aggravated the Veteran's obstructive sleep apnea. *The clinician must address both causation and aggravation separately.? **The examiner is advised that aggravation means any incremental increase in disability in nonservice-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. ***The examiner must consider and address the following in arriving at his or her opinion: 1. The AOJ conceded that the Veteran has a current disability of obstructive sleep apnea. Rating Decision - Narrative, dated January 25, 2023. 2. Dr. W.R.'s August 2021 VA sleep apnea examination report. See C&P Exam, received December 15, 2022. 3. Dr. T.C.'s July 2021 VA psychiatric examination report, which stated, "It is noted that, although not entirely clear why, research indicates that there is a higher prevalence of OSA among people with PTSD and PTSD symptoms can be exacerbated by sleep apnea." C&P Exam, received July 1, 2021. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. Schedule the Veteran for a new examination with an appropriate clinician to determine the nature and likely etiology of his current migraine headache disability. A complete history from the Veteran should be obtained and recorded. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination and this review should be acknowledged in the report. Thereafter, the examiner must respond to the following prompts: (a.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's headache disability has its onset in or was incurred in service. (b.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's headache disability was caused or aggravated by one - or any combination - of the Veteran's service-connected disabilities. *The clinician must address both causation and aggravation separately.? **The examiner is advised that aggravation means any incremental increase in disability in nonservice-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. ***The examiner must consider and address the following in arriving at his or her opinion: 1. The AOJ conceded that the Veteran has a current disability of migraine headaches and that the "evidence shows that a qualifying event, injury, or disease had its onset during your service. Service treatment record dated January 18, 1969 showed you complained of headaches for three days disability of obstructive sleep apnea. Rating Decision - Narrative, dated November 25, 2022. 2. Dr. T.H.'s VA Headaches examination report. See C&P Exam, receivedMay 31, 2022. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. Schedule the Veteran for a new examination with an appropriate clinician to determine the nature and likely etiology of his current skin condition disability. A complete history from the Veteran should be obtained and recorded. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination and this review should be acknowledged in the report. Thereafter, the examiner must respond to the following prompts: (a.) Solicit lay statements regarding the onset, severity, and chronicity of the Veteran's reported skin-related symptoms and any associated functional deficits. (b.) Identify all diagnoses in the evidence of record that reasonably encompass the skin-related reported by the Veteran (c.) Opine whether the Veteran's current skin-related issues were either clearly and unmistakably (obvious, manifest, and undebatable) preexisted service or were clearly and unmistakably (obvious, manifest, and undebatable) caused by a preservice injury. (d.) If the Veteran did have skin issues that preexisted active military service or were caused by a preservice injury, discuss whether clear and unmistakable (obvious, manifest, and undebatable) evidence establishes the Veteran's skin-related issues were NOT aggravated during active military service beyond their normal progression. (e.) If the Veteran's skin-related issues DID NOT preexist service or were not caused by a preservice injury, discuss whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's skin-related disability has its onset in or was incurred in service. ***The examiner must consider and address the following in arriving at his or her opinion: 1. The AOJ conceded the following: "You have been diagnosed with a disability. LHI examination dated February 26, 2021 showed examiner noted tinea versicolor is still diagnosed but quiescent;" and "The claimed issue existed prior to military service. Service treatment records show you were diagnosed with tinea versicolor at entrance to service. The claimed issue was treated during military service. Service treatment records show treatment for rashes beginning in December 1968." Rating Decision - Narrative, dated November 25, 2022. 2. J.M.'s VA examination report. See C&P Exam, received February 26, 2021. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Schedule the Veteran for a new examination with an appropriate clinician to determine the nature and likely etiology of his current erectile dysfunction disability. A complete history from the Veteran should be obtained and recorded. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination and this review should be acknowledged in the report. Thereafter, the examiner must respond to the following prompts: (a.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's erectile dysfunction disability has its onset in or was incurred in service. (b.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's erectile dysfunction disability was caused or aggravated by one - or any combination - of the Veteran's service-connected disabilities. *The clinician must address both causation and aggravation separately.? **The examiner is advised that aggravation means any incremental increase in disability in nonservice-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. Upon completion of the preceding Directives, adjudicate the claim for entitlement to a TDIU. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Cross, A. 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.