Citation Nr: A25041218 Decision Date: 05/06/25 Archive Date: 05/06/25 DOCKET NO. 230329-334691 DATE: May 6, 2025 ORDER A rating in excess of 10 percent, but no higher, for Hepatitis C, effective February 19, 2013 is granted. A rating in excess of 10 percent for right eye cataract and glaucoma is denied. A separate 10 percent rating under Diagnostic Code (DC) 6011 from February 19, 2013 for right eye cataract and glaucoma is granted. A separate 10 rating for eye pain and pressure under DC 7804 for right eye cataract and glaucoma at 10 percent from February 19, 2013 is granted. REMANDED Entitlement to service connection for heart disease is remanded. Entitlement to service connection for degenerative disc disease of the cervical spine to include rheumatoid arthritis and osteoarthritis of the cervical spine is remanded. Entitlement to service connection for rheumatoid arthritis is remanded. Entitlement to service connection for osteoarthritis is remanded. Entitlement to service connection for emphysema is remanded. FINDINGS OF FACT 1. The evidence is in approximate balance that from February 19, 2013, the Veteran's Hepatitis C manifested with symptoms no worse than intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and upper right quadrant pain) having a total duration of at least one week, but less than two weeks, during the past twelve-month period. 2. The probative evidence is against a finding that the Veteran had incapacitating episodes related to his Hepatitis C for the entire period on appeal. 3. The Veteran's Hepatitis C is undetectable and resolved in 2018. 4. From February 19, 2013, the Veteran's pre-operative right eye cataract and glaucoma manifested with corrected vision of 20/40, concentric contraction of the visual field of between 46 to 60 degrees unilaterally, continuous medication for his glaucoma, with symptoms of eye pain, eye pressure, flashes, floaters, and sensitivity to light. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating, but no higher, for Hepatitis C from February 19, 2013 are met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.114, DC 7354. 2. The criteria for a rating in excess of 10 percent for right eye cataract and glaucoma effective February 19, 2013 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.14, 4.25, 4.3, 4.6, 4.7, 4.76, 4.79, DC 6027-6013, 6011, 7804. 3. The criteria for a separate 10 percent rating under DC 6011 from February 19, 2013 for right eye cataract and glaucoma are met. 8 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.14, 4.25, 4.3, 4.6, 4.7, 4.76, 4.79, DC 6011. 4. A separate 10 rating for eye pain and pressure under DC 7804 for right eye cataract and glaucoma at 10 percent from February 19, 2013 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.14, 4.25, 4.3, 4.6, 4.7, 4.76, 4.79, DC 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1973 to February 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2023 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). In the March 2023 VA Form 10182, Decision Review Request: Board Appeal, the Veteran referenced the January 2023 decision elected the Board's Direct Review docket. Based upon the selection of the Direct Review option, the Board may only consider the evidence of record as of January 25, 2023-the date of the rating decision on appeal. See 38 C.F.R. § 20.301. If the Veteran submitted evidence that was added to the record after January 25, 2023, the Board did not consider it. If the Veteran wishes to have VA consider any evidence that was not considered, a supplemental claim should be submitted identifying such evidence. See 38 C.F.R. § 3.2501. After the VA received the VA Form 10182, the submitted a VA 21-22 appointing the above listed attorney as his representative. In a January 28, 2025 letter, the Board acknowledged this attorney as the Veteran's representation and provided noticed that argument may be submitted in support of the pending appeal. 38 C.F.R. § 20.5. The Board held the case for 30 days to allow for the submission of any argument. The record does not reflect that any was submitted. As such, the Board will now proceed to adjudicate this appeal. 1. An increased rating of 10 percent but no higher for Hepatitis C effective February 19, 2013 is granted. In a VA Form 21-4238 Statement in Support of Claim, the Veteran contended that his Hepatitis C (Hep C) warrants a compensable rating. The Veteran reported experiencing fatigue, joint pain, upper quadrant pain, and incapacitating episodes. Further, the Veteran asserts that the VA examination was inadequate since he was not provided a liver function test that he believes would have shown the extent of his liver damage. The January 2023 rating decision granted service connection for hepatitis C and assigned and initial noncompensable rating, effective February 19, 2013. As such, the rating period on appeal begins with this grant of service connection. The Veteran's hepatitis C is evaluated under Diagnostic Code 7354. When hepatitis is non-symptomatic, a 0 percent rating is assigned. A 10 percent rating requires intermittent fatigue, malaise, and anorexia, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least one week, but less than two weeks, during the past 12-month period; a 20 percent rating requires daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period; a 40 percent rating requires daily fatigue, malaise, and anorexia, with minor weight loss and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past 12-month period; a 60 percent rating requires daily fatigue, malaise, and anorexia, with substantial weight loss (or other indication of malnutrition), and hepatomegaly, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks during the past 12-month period, but not occurring constantly; and a 100 percent rating requires near-constant debilitating symptoms (such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain). 38 C.F.R. § 4.114, DC 7354. Note (1) in Diagnostic Code 7354 directs that sequela, such as cirrhosis or malignancy of the liver, should be evaluated under an appropriate diagnostic code, but the same signs and symptoms should not be used as the basis for evaluation under Diagnostic Code 7354. Note (2) provides that, for purposes of evaluating conditions under Diagnostic Code 7354, "incapacitating episode" means a period of acute signs and symptoms severe enough to require bed rest and treatment by a physician. On May 19, 2024, VA revised DC 7345, Progressive chronic liver disease requiring use of both parenteral antiviral therapy (direct antiviral agents), and parenteral immunomodulatory therapy (interferon and other); and for six months following discontinuance of treatment: A 100 percent rating is warranted for progressive chronic liver disease requiring use of both parenteral antiviral therapy (direct antiviral agents), and parenteral immunomodulatory therapy (interferon and other); and for six months following discontinuance of treatment. A 60 percent rating progressive chronic liver disease requiring continuous medication and causing substantial weight loss and at least two of the following: (1) Daily fatigue, (2) malaise, (3) anorexia, (4) hepatomegaly, (5) pruritus, and (6) arthralgia. A 40 percent rating is warranted for progressive chronic liver disease requiring continuous medication and causing minor weight loss and at least two of the following: (1) Daily fatigue, (2) malaise, (3) anorexia, (4) epatomegaly, (5) pruritus, and (6) arthralgia. A 20 percent rating is warranted for chronic liver disease with at least one of the following: (1) Intermittent fatigue, (2) malaise, (3) anorexia, (4) hepatomegaly, or (5) pruritus. A 0 percent rating is warranted for a previous history of liver disease, currently asymptomatic. The Veteran received two VA examinations during the open evidence window during the rating period on appeal (which the Board sees as going until the issuance of this decision). The first VA examination was in January 2020. The Veteran was diagnosed with Hepatitis C in 2013, however the examiner found that it was diagnosable by lab value and the Veteran's weight loss in 2009. At the January 2020 VA examination lab testing was performed. The Veteran's only symptom was intermittent fatigue. The January 2020 VA examiner found that the Veteran had no incapacitating episodes due to his Hepatitis C. Further, the Veteran did not have a diagnosis of cirrhosis of the liver nor any of the signs or symptoms attributable to cirrhosis. Additionally, the Veteran did not undergo a liver transplant, was never hospitalized awaiting a transplant, was not a liver transplant candidate, and had no injury to the liver. Laboratory results showed his Hepatitis C was not detected. The January 2023 VA examiner found that his Hepatitis C had resolved although the Veteran reported still experiencing fatigue. The Veteran reported that he was not currently being treated for Hepatitis C. The January 2023 VA examiner found that the Veteran had no symptoms of Hepatitis C. Further, the Veteran had no incapacitating episodes for his Hepatitis C within the past 12 months. The January 2023 VA examiner also found no signs and symptoms of cirrhosis of the liver. Although the January 2023 VA examiner did not perform lab test, lab results were cited in the DBQ from November 2022. A review of the Veteran's treatment records show that the Veteran was successfully treated for 8 weeks with Harvoni, and that his Hepatitis became undetectable and was not treated after blood test, taken 12 weeks after his treatment, confirm it was undetectable and no longer present in his blood. See Capri received 3/11/2020 at page 185. The results of the treatment and sustained undetectable labs appear in the Veteran's records from 2018. Accordingly, the Board finds that the 8-week treatment began in July 2017 and was completed in January 2018. See Capri received 9/20/2017 at page 27. Prior to the resolution of the Veteran's Hepatitis C, his treatment records show complaints of mild fatigue and occasional upset stomach. See Capri received 9/20/2017 at page 27. Otherwise, medical treatment records do not show complaints related to his Hepatitis C. Additionally, relevant treatment records show that the Veteran denied fever, chills, and weight loss. Id. The Board finds that the Veteran is entitled to a rating of 10 percent, but no higher, for intermittent fatigue, malaise, and anorexia. Although there is no specific diagnosis of malaise and anorexia, the Board finds that the evidence is in approximate balance that the Veteran met the requirements for a 10 percent rating from the date of claim based upon the finding of intermittent fatigue in the January 2020 VA examination and his treatment records that noted mild fatigue and upset stomach while the Veteran was being treated for Hepatitis C. Additionally, the Board finds that the Veteran had issues with maintaining a healthy weight as noted in the January 2020 VA examination. Accordingly, a 10 percent rating, but no higher, from February 19, 2013 is warranted. Although the evidence of record shows that the Veteran's Hepatitis C resolved in January 2018 after lab results confirmed his successful treatment, the Board finds that given the Veteran's continued complaints of fatigue, and the January 2020 VA examiners finding that his fatigue caused functional loss, the evidence is in approximate balance that the 10 percent rating should be continued throughout the rating period on appeal although Hepatitis C has resolved. Further, though the Veteran has argued that he has symptoms that would warrant the next higher 20 percent rating, such as daily fatigue, joint pain, upper quadrant pain, and incapacitating episodes, the Board finds that there is persuasive evidence against a 20 percent rating. Under DC 7354, a 20 percent rating requires "daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period." As stated above, the Veteran's VA examiners and his medical treatment records show that his Hepatitis C never caused incapacitating episodes since although he was treated with medication for that 8-week period, his symptoms were never severe enough to require bedrest. DC 7354, Note (2). In fact, his treating physician described his symptoms as "mild". See Capri received 9/20/2017 at page 27. Further, the January 2020 VA examination finding of "intermittent fatigue" and his treatment records showing diagnoses of "mild fatigue", all go against an assertion that his fatigue was "daily" as required for the next higher rating. Similarly, under the criteria effective in May 2024, the Board does not find that the evidence in an open window shows a rating in excess of a 10 percent evaluation is warranted. As the probative evidence does not show daily fatigue, malaise, and anorexia (without weight loss or hepatomegaly), requiring dietary restriction or continuous medication, or; incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least two weeks, but less than four weeks, during the past 12-month period. The Board acknowledges the Veteran's contention that VA should have performed a liver function test in a March 2023 statement. The more recent VA examination report in the open evidence window from late 2022 indicates that diagnostic testing was done in November 2022. The record does not reflect that the Veteran possess the education, skills, or training to assess when liver function tests are needed. The statement does not indicate anything irregular about the November 2022 results. In light of the foregoing, the Board finds there has not been a pre-decisional duty to assist error by the RO and it has considered the relevant, competent lay and medical evidence in assessing the level of disability regarding the Veteran's hepatitis C. In sum, the Board finds that a 10 percent rating, but no higher, for Hepatitis C from February 19, 2013 is granted. 2. An increased rating of 30 percent for right eye cataract and glaucoma, the maximum evaluation allowed for visual impairment of one eye, effective February 19, 2013 is granted. The January 2023 rating decision granted service connection for cataract, right eye, and assigned an initial noncompensable rating, effective February 19, 2013. In the Veteran's 10182 Notice of Disagreement, the Veteran disagreed with the noncompensable rating of his right eye cataract. This rating decision stated that the noncompensable rating was based on no incapacitating episodes, normal visual acuity, and normal visual fields. The record reflects that the RO issued, in February 2025, a subsequent rating decision, that recharacterized the eye disability as glaucoma with cataract, right eye (previously cataract, right eye) and assigned a10 percent disabling rating, effective February 19, 2013. Although the February 2025 rating decision is outside the rating decision on appeal, the Board finds that the grant of service connection for glaucoma and the 10 percent rating for right eye glaucoma with cataract are favorable findings, and therefore the Board will consider whether an increased rating more than 10 percent for the right eye is warranted from February 19, 2013. 38 C.F.R. § 3.104(c). Evaluations of defective vision are from noncompensable to 100 percent based on organic impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. §§ 4.76 (a), 4.79. The examination for visual impairment must be conducted by a licensed optometrist or by a licensed ophthalmologist and the examiner must identify the disease, injury, or any other pathologic found. 38 C.F.R. § 4.76 (b). Examination of visual fields or muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Id. Unless medically contraindicated, the fundus must be examined with the Veteran's pupils dilated. Id. When both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, the evaluation is determined by separately evaluating the visual acuity and visual field defect (expressed as a level of visual acuity) and combined under the provisions of 38 C.F.R. § 4.25. See 38 C.F.R. § 4.77(c). Unless otherwise directed, evaluate diseases of the eye under the General Rating Formula for Diseases of the Eye. 38 C.F.R. § 4.79, DC 6000 through 6009. Impairment of Visual Acuity is rated under DCs 6061 through 6066. Impairment of Visual Fields is rated under DCs 6080 through 6081. Ratings for Impairment of Muscle Function are rated under DC 6090 and 6091. The Veteran is currently rated pursuant to 38 C.F.R. § 4.79, DC 6027-6013. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. In this case, the Veteran is currently rated for his right eye glaucoma and cataract under the General Rating Formula for Diseases of the Eye. Under the former criteria, DC 6013 instructed to evaluate pursuant to visual impairment due to open-angle glaucoma. Under the revised criteria, DC 6013 instructs to evaluate pursuant to the General Rating Formula for Diseases of the Eye. Both the former and revised criteria indicate that a minimum 10 percent rating was warranted if continuous medication was required. Cataracts is rated under DC 6027. Both the former and revised criteria distinguish preoperative and postoperative cataracts. For preoperative cataracts, the former criteria instructed to evaluate based on visual impairment and the revised criteria instruct to evaluate under the General Rating Formula for Diseases of the Eye. For postoperative cataracts, both the former and revised rating criteria distinguish between pseudophakia and aphakia. If there is a replacement lens present (pseudophakia), then the former criteria instructed to evaluate based on visual impairment whereas the revised criteria instruct to evaluate under the General Rating Formula for Diseases of the Eye. If there is no replacement lens (aphakia), both the former and revised criteria instruct to evaluate based on aphakia, which is DC 6029. The General Rating Formula for Diseases of the Eye states disabilities of the eye should be evaluated on the basis of either visual impairment due to the particular condition or incapacitating episodes, whichever results in a higher evaluation. Id. A compensable 10 percent disability rating is warranted where there is documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months. 38 C.F.R. § 4.79. Note (1) states that an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Id. A compensable 10 percent disability rating is warranted where vision in one eye (the poorer eye) is 20/50 and the other eye is 20/50 or 20/40; vision in one eye (the poorer eye) is 20/70 and the other eye is 20/40; or vision in one eye (the poorer eye) is 20/100 and vision in the other eye is 20/40. 38 C.F.R. § 4.79, DC 6066. Here, the Veteran is only service connected for a right eye disability. Subject to the provisions of § 3.383(a), if visual impairment of only one eye is service connected, the visual acuity of the other eye will be considered to be 20/40 for purposes of evaluating the service-connected visual impairment. 38 C.F.R. § 4.75(c). The evaluation for visual impairment of one eye must not exceed 30 percent unless there is anatomical loss of the eye. Id.; 38 C.F.R. § 4.75(d). The evaluation for visual impairment of one eye should be combined with other disabilities of the same eye that are not based on visual impairment (e.g., disfigurement under DC 7800). 38 C.F.R. § 4.75(d). Impairment of Visual Fields is rated under DCs 6080 through 6081 based on the average concentric contraction of the visual field of each eye; asymmetric impairments are converted to their visual acuity equivalents. 38 C.F.R. §§ 4.77, 4.79. Compensable ratings are provided for loss of temporal half of visual field, loss of nasal half of visual field, loss of inferior half of visual field, loss of superior half of visual field, concentric contraction of visual field with the remaining field of at most 60 degrees, or unilateral scotoma. 38 C.F.R. § 4.79. The Veteran was provided two VA examinations during the open evidence window in January 2020 and November 2022. At the January 2020 VA examination, the Veteran reported taking medication, Latanoprost, at bedtime. He reported experiencing flashes, floaters, eye pain, and pressure in his eyes. The Veteran also reported diminishing central vision in his non-service connected left eye. The Veteran's corrected distance measured 20/40 in his right eye. Therefore, the Veteran would be entitled to a noncompensable rating since his corrected vision in the right eye is 20/40 and the non-service connected left eye is 20/40 for the purposes of evaluating visual acuity. 38 C.F.R. § 4.75(c). The Veteran's average concentric contraction of the visual field for the right eye was 45.625, which when round to the nearest degree is 46. Accordingly, under the Ratings for Impairment of Visual Fields, the Veteran is entitled to a 10 percent rating for his remaining field of 46 to 60 degrees unilateral. Therefore, the Veteran having a noncompensable rating for visual acuity but a 10 percent rating for visual field impairment, means he is entitled to a 10 percent rating based on the January 2020 VA examination. At the November 2022 VA examination, the Veteran reported being off his glaucoma medication for 5 months and was unable to recall his prior medication. The Veteran reported that his right eye was sensitive to light. At the November 2022 VA examination, the Veteran's corrected vision in his right eye was 20/40. Therefore, the Veteran would be entitled to a noncompensable rating since his corrected vision in the right eye is 20/40 and the non-service connected left eye is 20/40 for the purposes of evaluating visual acuity. 38 C.F.R. § 4.75(c). Although the November 2022 VA examiner did not document visual field testing in the DBQ, the Goldman Visual Field Chart was included and the Veteran had average concentric contraction of the visual field for the right eye was 49.375, which when round to the nearest degree is 49. Accordingly, under the Ratings for Impairment of Visual Fields, the Veteran is entitled to a 10 percent rating for his remaining field of 46 to 60 degrees unilateral. Therefore, the Veteran having a noncompensable rating for visual acuity but a 10 percent rating for visual field impairment, means he is entitled to a 10 percent rating based on the November 2022 VA examination. The Board has also considered whether the Veteran should be rated based on incapacitating episodes. A review of the Veteran's treatment record shows the use of medication, Latanoprost, for his glaucoma, and notation of his cataract and glaucoma in the right eye by history. In 2013, the Veteran had 3 visits for treatment of his eye disability. See Capri received 12/30/2013 at pages 194, 201, and 57. After 2013, the Board finds that the Veteran's medical treatment records only show his eye disability in his history but is silent for ongoing clinical visits. Therefore, since rating the Veteran based on incapacitating episodes would not result in a higher rating, the Board will rate the Veteran on the basis of visual acuity. 38 C.F.R. § 4.79. The Board has considered whether the Veteran has impairment of muscle function, however the Veteran does not have diplopia. See C&P Exam received 3/16/2020 at page 5; see also C&P Exam received 1/12/2023 at page 5. The Board has also considered other criteria under 38 C.F.R.§ 4.79, however DC 6027 for the Veteran's cataract, which is preoperative, instructs that it should be rated under the General Rating Formula for Diseases of the Eye. Lastly, the Board has also considered whether a rating for the Veteran's symptoms that are not compensated under DC 6027 and DC 6013 are warranted. Under the anti-pyramiding provision of 38 C.F.R. § 4.14, the evaluation of the "same disability" or, more appropriately in this case, the "same manifestation" under various diagnoses is to be avoided. For purposes of determining whether the Veteran is entitled to separate ratings for different problems or residuals of an injury, such that separate evaluations do not violate the prohibition against pyramiding, the critical element is that none of the symptomatology for any one of the conditions is duplicative of or overlapping with the symptomatology of the other two conditions. Esteban v. Brown, 6 Vet. App. 259 (1994). In Morgan v. Wilkie, the Court of Appeals for Veterans Claims (the Court) held that "VA's duty to maximize benefits requires it first to exhaust all schedular alternatives for rating a disability before the extraschedular analysis is triggered." The Court specifically listed secondary service connection as a "powerful alternative" to extraschedular referral. Morgan v. Wilkie, 31 Vet. App. 162, 164, 167 (2019). As such, the Board looks to alternative DCs to see if they are available to compensate the Veteran's service-connected right eye symptomatology. At the VA examinations, the Veteran reported experiencing flashes, floaters, and light sensitivity in his right eye. Although there is not a specific rating for flashes, floaters, and light sensitivity, the Board finds that DC 6011 which compensates for retinal scars, atrophy, or irregularities and provides a 10 percent rating for localized scars, atrophy, or irregularities of the retina, unilateral or bilateral, that are centrally located and that result in an irregular, duplicated, enlarged, or diminished image is analogous to the Veteran's symptomatology. 38 C.F.R. § 4.79. Accordingly, the Board finds that a separate 10 percent rating under DC 6011 from February 19, 2013 is also warranted. This is the only/maximum rating under this DC. The Veteran also reported ocular pain and pressure in his right eye. The Board finds that a 10 percent rating under DC 7804 scar(s), unstable or painful is analogous to the Veteran's report of right eye pain and pressure. Accordingly, a separate compensable rating for eye pain and pressure under DC 7804 at 10 percent from February 19, 2013 is also granted. While the Veteran's indicates that his right eye is worsening in a March 2023 statement, this is outside the applicable evidence window stated above and there the Board finds that there was not a pre-decisional duty to assist error in not getting a VA examination by the RO. If the Veteran believes there is a worsening, then they are advised to file the proper claim form with VA noting such. In sum, with the separate ratings awarded in this decision, the Veteran is receiving the maximum benefit for his right eye with a combined rating of 30 percent. 38 C.F.R. §§ 4.25, 4.75(d). REASONS FOR REMAND 1. Entitlement to service connection for heart disease is remanded. At the January 2019 Board hearing, the Veteran testified that he served on the USS Kitty Hawk in the offshore waters of Vietnam. A review of the Veteran's records reveals that he served on the USS Kitty Hawk from September 1, 1974 to February 12, 1975 during the Vietnam Era. However, it seems that there was no development to confirm his Blue Water Veteran status. The Board finds that it was a pre-decisional duty to assist error to not develop the record and confirm whether the Veteran was a Blue Water Veteran, which may entitle him to secondary service connection for his hypertensive heart disease given the Blue Water Navy Vietnam Veterans Act of 2019 (the Act) and the PACT Act. 38 C.F.R. § 20.802(a). Although, hypertensive heart disease is not a presumptive condition, hypertension was recently added to the list of diseases associated with herbicide agent exposure under the PACT Act. See 117 Pub. L. 168; 2022 Enacted S 3373; 117 Enacted S 3373; 136 Stat. 1759. The Blue Water Navy Vietnam Veterans Act of 2019 created new statutory requirements for the adjudications of certain claims based on veterans' herbicide agent exposure in the offshore waters of the Republic of Vietnam during the period from January 9, 1962, to May 7, 1975, in or near the Korean Demilitarized Zone during the period from September 1, 1967, to August 31, 1971, and in Thailand during the period from January 9, 1962, to May 7, 1975. Accordingly, the Board will remand this claim to confirm whether the Veteran served in the offshore waters of Vietnam. 2. Entitlement to service connection for degenerative disc disease of the cervical spine to include rheumatoid arthritis and osteoarthritis of the cervical spine is remanded. 3. Entitlement to service connection for rheumatoid arthritis is remanded. 4. Entitlement to service connection for osteoarthritis is remanded. At the January 2019 Board hearing, the Veteran asserted that his arthritis was caused by manual labor required for his MOS as an Aircraft Mechanic. See Hearing Transcript at page 13. In an Appellate Brief filed by his prior representative, the Veteran asserted that his osteoarthritis/rheumatoid arthritis began during service and his symptomatology has continued ever since service. By way of background, in a January 2019 VA examination, the Veteran was diagnosed with osteoarthritis and rheumatoid arthritis of the back and cervical spine. The Veteran is already service connected for degenerative disc disease to include ankylosis spondylosis and rheumatoid arthritis of the lumbar spine from February 2013 at 40 percent disabling. In his VA Form 10182 Notice of Disagreement, the Veteran did not disagree with the rating and/or the effective date, and therefore rheumatoid arthritis and osteoarthritis pertaining to the lumbar spine is not before the Board. That said, the Veteran disagreed with the denial of his claim for his cervical spine condition. As a preliminary matter the Board finds that his claims of service connection for osteoarthritis and rheumatoid arthritis are rated under the specific joint involved based on limitation of motion. 38 C.F.R. § 4.71a, DC 5002, 5003. Accordingly, the Board finds that the issue before it is: "whether service connection for a cervical spine condition to include osteoarthritis and/or rheumatoid arthritis of the cervical spine is warranted", and not separate claims for rheumatoid arthritis and osteoarthritis. Further, the Board finds that the Veteran has not asserted, nor does the record contain evidence, that his osteoarthritis and/or rheumatoid arthritis manifest in any other joint except his cervical spine and his now service-connected lumbar spine. In fact, the record shows that the joint involvement of his arthritis is limited to his cervical spine and his thoracolumbar spine. See C&P Exam received 3/25/2020 at page 3. Accordingly, the Board will address whether service connection for a cervical spine condition to include osteoarthritis and rheumatoid arthritis is warranted. In the September 2022 Board decision, this matter was remanded to associate with the claims file outstanding treatment records since September 2017. However, although a review confirms that additional treatment records were associated with the file as directed in the September 2022 Board decision, there was no addendum opinion provided that considered the newly associated medical records. The Board observes that this was not a specific directive in the September 2022 Board decision. However, the Board cannot make medical determinations, and therefore an addendum opinion that considers the newly associated medical treatment records is needed. Accordingly, the Board having found a pre-decisional duty to assist error will remand this matter for an addendum opinion. 38 C.F.R. § 20.802(a). 5. Entitlement to service connection for emphysema is remanded Under the PACT Act, VA generally must provide a medical examination when a veteran shows evidence of both a disability and participation in a TERA during active service when the evidence is insufficient to establish service connection for the disability. The examiner must consider (1) "the total potential exposure through all applicable military deployments of the veteran" and (2) "the synergistic, combined effect of all toxic exposure risk activities of the veteran." There is an exception to the examination requirement: VA does not have to provide a medical exam if it determines that there is no indication of an association between the disability and the toxic exposure risk activity (TERA). Here, the January 2023 rating decision contains a favorable finding of a current disability of emphysema as contained in the January 2020 VA examination report. Additionally, the record, at the time of the January 2023 rating decision, contained evidence of the Veteran's military occupation of aircraft mechanic, as noted on the DD Form 214, and that the Veteran served aboard the USS Kitty Hawk per military personnel records associated with the claims file. Based on the foregoing, the Board finds that there was a pre-decisional duty to assist error as the record indicate a TERA examination/opinion and development of associated VA evidence under the PACT Act. 38 U.S.C. § 1168. These matters are REMANDED for the following action: 1. Attempt to verify the Veteran's asserted in-service exposure to herbicide agents. Specifically, the Veteran's records show that he served on the USS Kitty Hawk from September 1, 1974 to February 12, 1975 during the Vietnam Era. Please confirm whether the Veteran served in the offshore waters of Vietnam. If more details are needed, contact the Veteran to request the information. If there is still insufficient information to verify exposure to herbicide agents, issue a Formal Finding outlining the steps taken to assist the Veteran and notify the Veteran of VA's inability to verify the in-service herbicide agent exposure. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's cervical spine condition diagnosed as osteoarthritis and rheumatoid arthritis of the cervical spine is at least as likely as not related to his MOS as an Aircraft Mechanic. The opinion should also consider whether the condition is entitled to presumptive service connection under 38 C.F.R. §3.309 (a). A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. After conducting any need development regarding in-service TERA, then obtain a medical opinion from a qualified clinician regarding the Veteran's currently diagnosed emphysema. The electronic claims file must be made available to the reviewing clinician for review in connection with the request for an opinion so that they may become familiar with the Veteran's relevant medical history. If the reviewing clinician determines that an in-person examination is needed in order to answer the following question(s), then such should be scheduled. After reviewing the claims file, the reviewing clinician should address the following: Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's emphysema is related or attributable to his service or to a TERA, such as exposure to asbestos? **In providing the opinion regarding TERA, the reviewing clinician must consider the total potential exposure through all applicable military deployments and service, as well as the synergistic and combined total effect of all TERA.** The reviewing clinician is advised that the Veteran is competent to report his symptoms and history and that such reports must be acknowledged and considered in formulating any opinion. The reviewing clinician must fully explain the rationale for any opinion, with citation to supporting clinical data/lay statements, as deemed appropriate. If the reviewing clinician cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide supporting rationale as to why an opinion cannot be made without resorting to speculation. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Dixon 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.