judge_norm: K A KENNERLY

disposition: granted

condition: tinnitus

condition: radiculopathy

condition: psychiatric

disposition: withdrawn

disposition: remanded

condition: heart

condition: hypertension

condition: headache

condition: neck

condition: knee

condition: erectile

condition: back

benefit: tdiu

benefit: smc

text: Entitlement to special monthly compensation (SMC) based on aid and attendance pursuant to 38 U.S.C. § 1114(l) is remanded.

text:
Citation Nr: 24004000
Decision Date: 01/26/24	Archive Date: 01/26/24

DOCKET NO. 20-20 801
DATE: January 26, 2024

ORDER

Entitlement to service connection for tinnitus is granted.

Entitlement to service connection for right lower extremity radiculopathy is granted.

Entitlement to service connection for left lower extremity radiculopathy is granted.

Entitlement to service connection for an acquired psychiatric disability, to include somatic symptom disorder, major depressive disorder and generalized anxiety disorder, as secondary to a service-connected low back disability, is granted.

Entitlement to service connection for gout is withdrawn.

REMANDED

Entitlement to service connection for a heart disability is remanded.

Entitlement to service connection for hypertension is remanded.

Entitlement to service connection for a right foot disability, to include pes planus, is remanded.

Entitlement to service connection for a left foot disability, to include pes planus, is remanded.

Entitlement to service connection for a bilateral hearing loss disability is remanded.

Entitlement to service connection for headaches is remanded.

Entitlement to service connection for a neck disability is remanded.

Entitlement to service connection for obstructive sleep apnea (OSA) (claimed as a respiratory disability) is remanded.

Entitlement to service connection for a right knee disability is remanded.

Entitlement to service connection for a left knee disability is remanded.

Entitlement to service connection for a right hand disability is remanded.

Entitlement to service connection for a left hand disability is remanded.

Entitlement to service connection for a right wrist disability, to include carpal tunnel syndrome (CTS), is remanded.

Entitlement to service connection for a left wrist disability, to include carpal tunnel syndrome (CTS), is remanded.

Entitlement to service connection for erectile dysfunction is remanded.

Entitlement to an initial increased rating in excess of 20 percent for a lumbosacral strain (herein low back disability) is remanded.

Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded.

Entitlement to special monthly compensation (SMC) based on aid and attendance pursuant to 38 U.S.C. � 1114(l) is remanded.

FINDINGS OF FACT

1. The appellant's tinnitus is related to his active service.

2. Competent evidence has identified the objective neurologic abnormalities of right and left lower extremity radiculopathy as associated with the appellant's service-connected low back disability.

3. The appellant has an acquired psychiatric disorder that is secondary to his service-connected low back disability.

4.  At the May 2022 Board hearing, prior to the promulgation of a Board decision, the appeal of service connection for gout was withdrawn.

CONCLUSIONS OF LAW

1. The criteria for service connection for tinnitus are met.  38 U.S.C. � 1131; 38 C.F.R. � 3.303.

2. The criteria for service connection for right and left lower extremity radiculopathy are met.  38 U.S.C. � 1131; 38 C.F.R. �� 3.303, 4.71a.

3. The criteria for service connection for an acquired psychiatric disorder, to include somatic symptom disorder, major depressive disorder and generalized anxiety disorder, as secondary to a service-connected low back disability, are met.  38 U.S.C. � 1131; 38 C.F.R. � 3.310.

4.  The criteria for withdrawal of the appeal of service connection for gout are met.  38 U.S.C. � 7105; 38 C.F.R. � 20.205.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The appellant served on active duty in the United States Army from May 1979 to July 1981.  He had additional Army Reserve service, to include periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA).

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2017 rating decision of the Department of Veterans Affairs' (VA) Veterans Benefits Administration (the agency of original jurisdiction (AOJ)).

The appellant participated in a Board hearing in May 2022.  A transcript of this proceeding is of record.

Entitlement to Service Connection for Tinnitus

Appellant's Contentions

The appellant has contended that he has tinnitus that had its onset during active service.

Legal Criteria

"Veterans may claim benefits for disabilities connected to their military service subject to statutory and regulatory requirements."  George v. McDonough, 142 S. Ct. 1953, 1957 (2022).  Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  See 38 U.S.C. � 1131; 38 C.F.R. � 3.303(a).

Generally, in order to establish direct service connection, three elements must be established: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury, which is often referenced as the "nexus" element. See Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Certain chronic diseases, including tinnitus as organic disease of the nervous system, will be presumed related to service if they were shown as chronic in service (or within a presumptive period) and there are subsequent manifestations of the same chronic diseases; or if they manifested to a compensable degree within a presumptive period following separation from service (in this case, one year); or if they were noted in service, with continuity of symptomatology since service.  See 38 U.S.C. �� 1101, 1112; 38 C.F.R. �� 3.303, 3.307, 3.309; Fountain v. McDonald, 27 Vet. App. 258, 271 (2015) ("[38 C.F.R.] � 3.309(a) includes tinnitus, at a minimum where there is evidence of acoustic trauma, as an "organic disease [] of the nervous system' ").

38 U.S.C. � 5107(b) states that "[w]hen there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, [VA] shall give the benefit of the doubt to the claimant" and 38 C.F.R. � 3.102 states that "[w]hen...a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim."  See also Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021) ("[I]f the positive and negative evidence is in approximate balance (which includes but is not limited to equipoise), the claimant receives the benefit of the doubt").

Analysis

Upon review, and after giving the benefit of the doubt to the appellant, it is found that the appellant's tinnitus began during his active service and that service connection is warranted.

Tinnitus is defined as "a noise in the ears, such as ringing, buzzing, roaring, or clicking."  See Dorland's Illustrated Medical Dictionary 1930 (32nd ed. 2012). The appellant is competent to report as to the onset and presence of tinnitus "because ringing in the ears is capable of lay observation."  See Charles v. Principi, 16 Vet. App. 370, 374 (2002).

The AOJ conceded that the appellant had a high probability of exposure to hazardous noise.  See Statement of the Case (SOC), March 2020 ("we ordered a VA examination and medial opinion because VA conceded a high probability of exposure to hazardous noise based on your military occupation of Cannon Crewman").

The referenced examination in the SOC and medical opinion was, in fact, only a VA opinion provided without examination of the appellant.  In this regard, audiologist K.R. provided a January 2017 VA opinion, which was noted to be based on "[r]eview of available records (without in-person or video telehealth examination)...because the existing medical evidence provided sufficient information on which to prepare the [Disability Benefits Questionnaire (DBQ)] and such an examination will likely provide no additional relevant evidence."  The opinion stated:

STRs were silent for tinnitus complaint and there was no significant in-service threshold shift present.  In the absence of an objectively verifiable noise injury, the association between claimed tinnitus and noise    exposure cannot be assumed to exist.  Tinnitus may occur following a single exposure to high-intensity impulse noise, long-term exposure to repetitive impulses, long-term exposure to continuous noise, or exposure to a    combination of impulses and continuous noise.  However, you would have to accept the scientifically unsubstantiated theory that tinnitus occurred as a result of some latent, undiagnosed noise injury.  IOM never stated that tinnitus could result from undiagnosed noise injuries. In most cases, tinnitus is accompanied by measurable hearing loss.  We recognize that the audiogram is an imperfect measurement.  Nevertheless, it is accepted as the objective basis for determining noise injuries.  Thus, there is no nexus of the Veteran's reported hearing loss and tinnitus to his military service.

After this opinion, the appellant testified, under oath, at the May 2022 Board hearing that, essentially, his tinnitus began during active service.  Specifically, his attorney asked him "how long have you had the kind of ringing in the ears, or buzzing of that tinnitus issue?" and the appellant replied:

[I]t was like that when I was in the field artillery, because back then, we wasn't required to wear earplugs back then doing them fire missions, shooting them tanks...firing them, being right up under them, them loud booms...That's when you hear the tingling and stuff in your ears...And then being around them tanks and them trucks and stuff like that, you know, you were right there with them...You didn't have to wear earplugs back in the early '70s.  In the late '70s and the early '80s, we wasn't required to wear earplugs.

The attorney further stated "[y]ou noticed the ringing at that time.  Is that something that stuck with you all these years?" and the appellant responded "[y]es."  Later in the hearing, the VLJ asked "you said that for the tinnitus, that had just been consistent since from when you were in service?" and the appellant responded "[r]ight."

In review, the appellant testified, under oath, that his tinnitus started in service and has continued since.  The appellant is competent to make this report, which represents positive evidence in favor of his claim.

On the other hand, the January 2017 VA opinion represented negative evidence to the appellant's claim, as the opinion was that there was no nexus between the appellant's tinnitus and his military service.  This opinion, however, is found to be inadequate.  As noted, the opinion was not based on an actual examination of the appellant.  As such, the appellant was not able to provide his competent lay statement as to the onset of tinnitus, which was later provided at the May 2022 Board hearing.  Lacking consideration of the appellant's prior medical history with respect to his competent report as to the onset of tinnitus, the January 2017 VA opinion is found to be inadequate.  See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) ("An opinion is adequate where it is based upon consideration of the veteran's prior medical history").

As the January 2017 VA opinion was inadequate, it would be appropriate to remand this claim in order to obtain a new VA opinion that sufficiently considers the appellant's lay evidence as to the in-service onset of tinnitus.  See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) ("Once [VA] undertakes the effort to provide an examination when developing a service-connection claim... [VA] must provide an adequate one").  Instead, reasonable doubt will be resolved in the appellant's favor and it is found that there is currently sufficient evidence to determine that the appellant's tinnitus began during his active service.  See 38 C.F.R. � 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); see also Mariano v. Principi, 17 Vet. App. 305, 312 (2003) ("it would not be permissible for VA to undertake...additional development if a purpose was to obtain evidence against an appellant's case").

As noted, the appellant competently testified, under oath, that his tinnitus started in service and has continued since.  Of record are service treatment records from the appellant's Reserve service, which may be viewed as being in conflict with the appellant's report of in-service onset of tinnitus.  In this regard, on Report of Medical History forms dated in May 1982, January 1983, June 1986 and September 1990, the appellant denied ever having or having now, ear, nose or throat trouble.  While these records could be viewed as conflicting with the report of an in-service onset of tinnitus, as noted above, tinnitus can be considered an organic disease of the nervous system and it therefore is not necessarily clear that a denial of ear trouble would encompass tinnitus.

Overall, when considering the evidence of record, with specific focus on the appellant's competent testimony under oath at the May 2022 Board hearing, there is at least an approximate balance of positive and negative evidence as to the issue of whether the appellant's tinnitus began during his active service.  As such, giving the benefit of the doubt to the appellant and resolving reasonable doubt in his favor, it is found that the appellant's tinnitus began during his active service.

In sum, the appellant's tinnitus is related to his active service.  As such, the criteria for service connection for tinnitus are met and, to this extent, the appellant's claim is therefore granted.  38 U.S.C. � 1131; 38 C.F.R. � 3.303.

Entitlement to Service Connection for Right Lower Extremity Radiculopathy

Entitlement to Service Connection for Left Lower Extremity Radiculopathy

Appellant Contentions

The appellant has not specifically contended that service connection is warranted for bilateral lower extremity radiculopathy.  These issues, however, are found to be reasonably raised by the evidence of record and accordingly require consideration.  Garner v. Tran, 33 Vet. App. 241, 246 (2021) ("In evaluating a veteran's claim, the Board is required to consider all theories of entitlement to VA benefits that are either raised by the claimant or reasonably raised by the record").

Analysis

Upon review, service connection is warranted for right and left lower extremity radiculopathy.

An issue on appeal is the initial increased rating claim for a low back disability.  This disability is currently assigned a 20 percent rating under 38 C.F.R. � 4.71a, Diagnostic Code (DC) 5237.  This DC is rated under the General Rating Formula for Diseases and Injuries of the Spine and the corresponding Note 1 states to "[e]valuate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate [DC]."

Evidence of record has identified right and left lower extremity radiculopathy, which is an objective neurologic abnormality, as associated with the appellant's service-connected low back disability.

In this regard, VA treatment records dated from May to June 2021 (from the Tampa VA Medical Center) variously noted lumbar radiculopathy.  For example, a May 2021 record noted "low back pain intermittently radiates down bilateral legs" and a diagnosis of lumbar radiculopathy.

In addition, the appellant submitted a private Back Conditions DBQ, completed in June 2022 by Dr. R.L.  Diagnoses were noted of lumbosacral strain and radiculopathy.  The DBQ documented, for the bilateral lower extremities, decreased muscle strength, hypoactive reflexes, decreased sensation to light touch, and positive straight leg raising test results.  It was further noted that the appellant had bilateral lower extremity radiculopathy with symptoms of constant and intermittent pain, paresthesias and/or dysesthesias and numbness.  The bilateral sciatic nerve was noted as affected.  Regarding the preceding findings, Dr. R.L. stated that such "are indicative of lower extremity radiculopathy secondary to [appellant's] service-connected spine condition."

In sum, competent evidence has identified the objective neurologic abnormalities of right and left lower extremity radiculopathy as associated with the appellant's service-connected low back disability.  As such, the criteria for service connection for right and left lower extremity radiculopathy are met and, to this extent, the appellant's claim is therefore granted.  38 U.S.C. � 1131; 38 C.F.R. �� 3.303, 4.71a.

Entitlement to Service Connection for an Acquired Psychiatric Disability

Appellant Contentions

The appellant has, essentially, contended that he has an acquired psychiatric disability that is secondary to his service-connected low back disability.

Legal Criteria

Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability.  38 C.F.R. � 3.310(a)-(b).

Secondary causation exists when, but for the service-connected disability, the non-service-connected was caused by a service-connected disability either in a direct, etiological way or via multiple steps in a causal chain.  Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023) (citations omitted).  Secondary aggravation exists when the non-service-connected disability not caused by a service-connected disability would be less severe were it not for a service-connected disability.  Id. at 1364.  For example, secondary aggravation may be established where the natural progression of the non-service-connected disability could have been arrested or improved but for the service-connected disability.  Id.

Analysis

Upon review, and after giving the benefit of the doubt to the appellant, service connection is warranted for an acquired psychiatric disability.

The appellant was not afforded a VA examination as part of this claim.

At the May 2022 Board hearing, the appellant's attorney referenced "multiple diagnoses of depression" and "much of that treatment, especially in recent years, is in the context of pain management."  The attorney also stated that "we contend that a lot of these conditions should be service-connected, but the back is a major, major point of contention when looking through these psychiatric records, specifically with regard to this chronic pain that [the appellant] is dealing with."  The appellant also provided testimony as to his chronic pain and how it impacts him.  See Board Hearing Transcript, May 2022, Pages 6-9.

VA treatment records support the appellant's contention.  In this regard, of record is a July 2018 treatment record, which was a psychology assessment completed by psychologist E.B.  The record noted that the appellant "endorsed symptoms of chronic pain.  He describes his chronic pain as sharp pain in his knee, neck, and back and numbness in his hands."  It was stated that the appellant "endorsed symptoms of depression...His symptoms are secondary to unemployment, financial stress (applying for SC from VA), medical issues (upcoming surgery to treat carpel tunnel; needs to lose weight to be a candidate for knee surgery), and chronic pain."  It was further stated that the appellant's "symptoms include: symptoms of chronic pain and related symptoms of depression and anxiety."  The psychologist noted diagnoses of somatic symptom disorder with predominant pain and depressive disorder due to another medical condition with anxious distress.

Also of record are various treatment records dated from December 2020 to July 2022 from D.H., who was noted to be an Advance Practice Registered Nurse (APRN) and to having the additional credential of being a board certified Psychiatric-Mental Health Nurse Practitioner (PMHNP-BC).

The initial December 2020 treatment record from this provider stated that the appellant "does acknowledge feeling depressed.  He complains of chronic musculoskeletal pain that interferes with his quality of life. He has a long history of low back pain, arthritis, and 'bad knees'...Pain has interfered with his quality of life.  When pain is prominent, he does endorse some mood lability as well."  D.H. provided  a diagnosis of major depressive disorder and stated that the appellant's "pain does play a significant role with regard to depressive symptoms."

Subsequent records from D.H. contained similar information, to include statements relating the appellant's pain to his depression, as well as to his anxiety.

A February 2021 record stated that the appellant "still endorses feeling depressed more often than not.  He attributes much of this to medical comorbidities.  In particular, he has chronic knee and back pain that limits his quality of life."  A diagnosis was again provided of major depressive disorder, with the same language from the December 2020 note that the appellant's "pain does play a significant role with regard to depressive symptoms."

A July 2021 record stated that the appellant "has chronic back pain which limits his quality of life."  A diagnosis was again noted of major depressive disorder, with the additional diagnosis provided of unspecified anxiety disorder.  D.H. stated that the appellant's "pain does play a significant role with regard to depressive/anxiety symptoms."

A February 2022 record stated that the appellant was "with a history of recurrent depression/anxiety complicated by chronic medical comorbidities" and that he "continues to have chronic pain and reports that medical comorbidities do limit his quality of life."  It was also noted that the appellant had "[a]nxiety specifically as it pertains to health-related concerns."  Diagnoses were noted of major depressive disorder and generalized anxiety disorder (GAD).  It was again noted that the appellant's "pain does play a significant role with regard to depressive/anxiety symptoms."

An April 2022 record contained the same diagnoses from the February 2022 record.  This record had a slightly different comment from D.H. that the appellant's "chronic pain has significantly contributed to the recurrent depressive symptom."

A May 2022 record stated "some degree of episodic anxiety and dysphoria persist.  He correlates this primarily to chronic pain" and "[h]e anticipates getting some injections in his back.  The pain in particular has been a limiting factor with regard to his quality of life.  He estimates that he will eventually have to submit for a knee replacement.  If pain was not as prominent, he estimates that he would feel much less depressed."  The same diagnoses were noted as the April 2022 record, along with the same notation about chronic pain significantly contributing to depressive symptoms.

A July 2022 record, which is the most recent record in the claims file from this provider, stated that the appellant "still experiences periods of dysphoria which essentially directly correlated to his pain symptoms" and also noted "[e]pisodic anxiety and dysphoria that correlates with pain."  Under the review of systems heading, noted was "[c]hronic neck, back, and bilateral knee pain" (this notation was included in all of the medical records from D.H. that have been discussed).  The same diagnoses were noted as the April and May 2022 records, along with the same notation about chronic pain significantly contributing to depressive symptoms.

In review of the outlined medical records, two medical professionals related acquired psychiatric disorders, at least in part, to the appellant's pain.  Psychologist E.B., in a July 2018 record, provided a diagnoses of somatic symptom disorder with predominant pain and depressive disorder due to another medical condition with anxious distress and noted "[h]is symptoms are secondary to... chronic pain."  APRN D.H., who treated the appellant from December 2020 to at least July 2022, provided diagnoses of major depressive disorder and generalized anxiety disorder, and stated "pain does play a significant role with regard to depressive symptoms," "pain does play a significant role with regard to depressive/anxiety symptoms" and "chronic pain has significantly contributed to the recurrent depressive symptom."  The records from D.H. are found to be particularly probative based on the fact that there were multiple records from different visits dated over a period of more than one year.

The appellant is service connected for a low back disability and pain has been recognized as a component of his disability.  See Rating Decision, August 2017 (noting a symptom of painful motion upon examination).  As outlined, low back pain was discussed in the relevant medical records.  Accordingly, the medical records related an acquired psychiatric disorder, at least in part, to the appellant's service-connected low back disability by way of the associated pain.

As noted, no VA examination was conducted for this claim.  Based on the evidence discussed, it would be appropriate to remand this claim in order to afford the appellant a VA examination and obtain a VA opinion specifically addressing secondary service connection.  See 38 U.S.C. � 5103A(d); 38 C.F.R. � 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006).  Instead, reasonable doubt will be resolved in the appellant's favor and it is found that there is currently sufficient evidence to determine that the appellant's has an acquired psychiatric disorder that is secondary to his service-connected low-back disability. See 38 C.F.R. � 3.304(c); see also Mariano v. Principi, 17 Vet. App. 305, 312 (2003).

Overall, when considering the evidence of record, with specific focus on the medical records discussed, there is at least an approximate balance of positive and negative evidence as to the issue of whether the appellant has an acquired psychiatric disorder that is secondary to his service-connected low back disability.  As such, giving the benefit of the doubt to the appellant and resolving reasonable doubt in his favor, it is found that the service connection is warranted.

In sum, the appellant has an acquired psychiatric disorder that is secondary to his service-connected low back disability.  As such, the criteria for service connection for an acquired psychiatric disorder, to include somatic symptom disorder, major depressive disorder and generalized anxiety disorder, as secondary to a service-connected low back disability, are met and, to this extent, the appellant's claim is therefore granted.  38 U.S.C. � 1131; 38 C.F.R. � 3.310.

Entitlement to Service Connection for Gout

The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. � 7105.  An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. � 20.205.  Withdrawal may be made by the appellant or by his or her authorized representative.  Id.  In the present case, the appellant has withdrawn his appeal of the issue of service connection for gout and, hence, there remain no allegations of errors of fact or law for appellate consideration as to this issue.

Specifically, at the March 2023 Board hearing, the VLJ stated "prior to going on to the record, you all indicated that you would like for me to withdraw the issue of entitlement to service connection for gout.  Is that correct" and the appellant's attorney responded "[y]es."  The VLJ then addressed the appellant and stated "you understand that by withdrawing that claim today, that at any time you can bring this claim again, but you will need to submit new evidence.  And for your awareness, that if you are granted entitlement to benefits, the date of that entitlement will be the same date as your new claim.  So, does all of that make sense?" and the appellant responded "[y]es."

Upon review, the Board finds that the oral withdrawal at the May 2022 Board hearing was "explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant."  See DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011); see also Acree v O'Rourke, 891 F.3d 1009 (Fed. Cir. 2018).

In sum, the Board finds that at the May 2022 Board hearing, prior to the promulgation of a Board decision, the appeal of service connection for gout was withdrawn and, accordingly, the Board does not have jurisdiction to review the appeal of this issue and it is dismissed.

REASONS FOR REMAND

Entitlement to Service Connection for a Heart Disability

Remand is warranted for this claim to attempt to obtain outstanding Social Security Administration (SSA) disability records.

VA's duty to assist includes attempting to obtain adequately identified relevant Federal records, to include SSA records.  See 38 U.S.C. � 5103A(c)(1)(C); 38 C.F.R. � 3.159(c)(3); Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010) (discussing VA's duty to assist in regard to obtaining SSA records and stating that "[a]s long as a reasonable possibility exists that the records are relevant to the veteran's claim, VA is required to assist the veteran in obtaining the identified records").

VA treatment records variously reference the appellant as being in receipt of SSA disability, to include references to such being related to a heart disability.  See VA Treatment Records, January 2012 ("Employment/income status: unemployed/[Social Security Disability Insurance (SSDI)]"),  August 2012 ("Occupation:  Retired.  Social security disability"), November 2012 ("Occupation: Social Security disability for heart condition"), April 2016 ("disabled due to heart problems"), November 2019 ("Occupation: disabled due to heart issues"), November 2020 ("He retired in 2010 due to medical problems including placement of the defibrillator.  He began to receive SSDI benefits after his retirement").

Accordingly, remand is warranted to attempt to obtain any SSA disability records available.

In addition, while on remand, outstanding VA treatment records must be obtained (the most recent records of record are dated in July 2022).

Finally, the records requested in this section, SSA disability records and VA treatment records, are potentially relevant to all the additional claims to be remanded.  As such, the remaining claims may be viewed as inextricably intertwined, at this time, with the heart disability claim.  See Harris v. Derwinski, 1 Vet. App. 180 (1991).  While the remaining claims will be discussed in turn, the records to be requested on remand will not be discussed again unless specifically necessary.

Entitlement to Service Connection for Hypertension

Remand is warranted to obtain a new VA opinion.

The appellant was afforded a VA examination for this claim in July 2017 and a Hypertension DBQ was completed.  A diagnosis was noted of hypertension, with a date of diagnosis of "1980's."  Under the medical history section, a date of onset was noted of "1980's" and it was stated that "[i]n the early 1980's he was diagnosed as having hypertension during a routine US Army office visit."  The course since onset was noted as persistent.

The clinician provided a negative direct service connection opinion.  The supporting rationale stated "I have reviewed the C-File and I do not see evidence that [the appellant] was treated for hypertension in service.  The currently diagnosed hypertension is less likely than not incurred in or caused by the high blood pressure that occurred during service."

This opinion is inadequate.  First, the rationale appeared to impermissibly require an in-service diagnosis for a nexus to exist and did not otherwise offer an explanation to support the negative direct service connection.  See 38 C.F.R. � 3.303(d) ("Postservice initial diagnosis of disease. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service"); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("It is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes probative value to a medical opinion").

Second, while the rationale referenced there being no evidence of treatment for hypertension in service, not addressed was an in-service elevated blood pressure reading.  A note to DC 7101 (Hypertensive vascular disease (hypertension and isolated systolic hypertension)) states that "[f]or purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater."  An August 1980 STR included a blood pressure reading with diastolic blood pressure greater than 90mm, specifically a reading of 150/110.  Lacking discussion of this relevant portion of the appellant's medical history renders the provided rationale inadequate.  See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007).

Third, the rationale also did not address a May 1982 Reserve examination report, which was conducted within one year of the appellant's separation from active service in July 1981.  This examination report included an elevated blood pressure reading of 130/98.  Also, a diagnosis was listed of "[e]levated blood pressure - instructed by doctor have follow-up with family physician."

Certain chronic diseases, including hypertension, will be presumed related to service if they were shown as chronic in service or within a presumptive period and there are subsequent manifestations of the same chronic diseases; or if they manifested to a compensable degree within a presumptive period following separation from service (in this case, one year); or if they were noted in service, with continuity of symptomatology since service.  See 38 U.S.C. �� 1101, 1112; 38 C.F.R. �� 3.303, 3.307, 3.309.

Given the relevancy of the one-year post service period for a hypertension claim, the VA opinion is inadequate without addressing the May 1982 Reserve examination report.

Overall, the prior VA opinion was inadequate and a new opinion, as outlined further in the remand directives below, is warranted.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

Entitlement to Service Connection for a Right Foot Disability

Entitlement to Service Connection for a Left Foot Disability

Remand is warranted to obtain a new VA opinion.

Initially, the appellant claimed service connection for a bilateral foot condition.  See VA Form 21-526EZ, October 2016.  The August 2017 rating decision on appeal characterized this claim as pes planus.  The issues have been recharacterized more broadly, and separately, as right and left foot disability claims.

The appellant was afforded a VA examination in July 2017 and a Foot Conditions DBQ was completed.  A diagnosis was noted of bilateral flat feet, with a date of diagnosis noted of 1979.  Under the medical history section, a date of onset was noted of "1980's" and it was stated that:

He began having symptoms of flat feet back in 1979.  He says that the constant training and exercising that was required caused this problem to occur.  He would have to walk at least three or more miles.  He had to walk with his full Army gear including his helmet rucksack in excess of 50 pounds and his weapons.  At the end of this walk or run he states that his feet were hurting.  His foot pain was relieved with resting.

The course of the condition since onset was noted as "has become worse."

The clinician also provided a negative direct service connection opinion.  The supporting rationale stated "the medical records do not support the pes planus was incurred in or caused by the gunshot wound that occurred during service.  I just don't see evidence of this.  The currently diagnosed pes planus was less likely than not incurred in or caused by the gunshot wound that occurred during service."

This opinion is inadequate.  First, the reference to a gunshot wound was related to a post-service incident, as this was referenced as occurring in October 1983, after the appellant's period of active service.  See Report of Medical History, June 1986.  As such, the negative direct service connection opinion only discussed a post-service incident.  Second, the opinion did not address, and seemingly impermissibly ignored, the appellant's lay statements, documented in the accompanying Foot Conditions DBQ, as to in-service onset of foot symptoms and that the course since onset was noted as "has become worse."  See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) ("it appears that the medical clinician impermissibly ignored the appellant's lay assertions"); Miller v. Wilkie, 32 Vet. App. 249, 260 (2020) ("The clinician must address the veteran's lay statements to provide the Board with an adequate medical opinion").

Overall, the prior VA opinion was inadequate and a new opinion, as outlined further in the remand directives below, is warranted.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

Entitlement to Service Connection for a Bilateral Hearing Loss Disability

Remand is warranted to afford the appellant a VA examination and to obtain a new VA opinion.

The appellant was not afforded a VA examination as part of this claim.  As discussed above in the tinnitus section, audiologist K.R. provided a January 2017 VA opinion, which was noted to be based on "[r]eview of available records (without in-person or video telehealth examination)...because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence."

A negative direct service connection opinion was provided, stating:

The C-file indicated that the Veteran served in the Army from 1979-81.  The Veteran's enlistment hearing exam showed normal hearing in both ears from 500 to 6000Hz. No separation hearing exam found, however, exams post active duty during the Veteran's reserve time from 1982-1990 showed normal hearing in both ears from 500 to 6000Hz with NO significant threshold shifts in either ear. Thus, there is no evidence of acoustic trauma or hearing loss in either ear...there is no nexus of the Veteran's reported hearing loss...to his military service.

Initially, 38 C.F.R. � 3.385 specifically defines when there is a hearing loss disability for VA purposes.  Without an examination, it is not clear whether the appellant in fact has a bilateral hearing loss disability for VA purposes, as the remaining evidence of record did not otherwise include the required audiometric test results.  Accordingly, it does not seem that it was appropriate in this case to only obtain a VA opinion, without an in-person examination.

In any event, the provided rational is inadequate.  In this regard, a portion of the opinion stated that "exams post active duty during the Veteran's reserve time from 1982-1990 showed normal hearing in both ears from 500 to 6000Hz."  Exams from this time, in fact, showed some degree of hearing loss, as a January 1983 Reserve Report of Medical Examination noted 25 decibels (dB) at 6000 Hertz (Hz) for the right ear; a June 1986 Reserve Report of Medical Examination noted 25 dB at 4000 Hz for the left ear; and a September 1990 Reserve Report of Medical Examination noted 25 dB at 500 Hz for the right ear and 30 dB at 4000 Hz for the left ear.  These findings showed some degree of hearing loss.  Hensley v. Brown, 5 Vet. App. 155, 157 (1993) ("the threshold for normal hearing is from 0 to 20 dB, and higher threshold levels indicate some degree of hearing loss").  As such, the VA opinion was based, at least in part, on an inaccurate factual premise that the appellant had normal hearing from 1982-1990 and it is accordingly found to be inadequate.  See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based upon an inaccurate factual premise has no probative value").

Overall, the prior VA opinion was inadequate and a new opinion, as outlined further in the remand directives below, is warranted.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

Entitlement to Service Connection for Headaches

Entitlement to Service Connection for a Neck Disability

Remand is warranted for these claims to afford the appellant a VA examination and obtain a VA opinion (which were not previously conducted/obtained).

With respect to a neck disability, the following dialogue (edited for relevancy) occurred at the May 2022 Board hearing between the appellant and his attorney:

Attorney: When we spoke about the neck, you mentioned that this was sort of something that over the years, the low back pain started to just climb, almost, and then it started to hurt your mid-back.  And as time went on, that continued to grow up, you know, upwards more and more, until it started to be in your neck.

Appellant: Right.

Attorney: Describe that process over the years.  I mean, so the neck was something that came about after you were dealing with the back pain for so long.

Appellant: Right.  Yes.  It seemed like it just started getting stiffer and stiffer, and since like --you know when a person's got --you ever have a stiff neck?  It just started getting more and more like that, and just got where I just couldn't hardly like turn your neck hardly, or turn it so far.  And it just started getting more and more like that.

Attorney: And you could sort of tell, as the years went by, that this was starting to progress?  You know, from being solely a low back pain problem, all of the sudden now it's, you know, maybe chest level, and then years go by, and it starts to impact the neck? And you mentioned increased stiffness throughout the years, that have really exacerbated all of that, too.

Appellant: Right.

Attorney: it's important that we get a sense from you about the things that you are capable of experiencing and describing to us, and some of that is the progression from this low backup to the neck.  Have you noticed --you know, you talked about the stiffness, and the pain that sort of started to elevate up the back a little bit.  Are you able to pinpoint --not necessarily, you know, day and week and month --but around what time you started to notice you were having problems with the neck?

Appellant: A couple of years ago

Attorney: Okay.  So, more recently than a lot of these other issues that we're talking about, that have been ongoing for --

Appellant: Right.

Attorney: --thirty-plus years.  Okay.

Appellant: Yes, it just got worse recently.

With respect to headaches, the following dialogue occurred at the May 2022 Board hearing between the appellant and his attorney:

Attorney: you mentioned to me previously that the headaches, which are on appeal here as well, these started a couple of years ago, around the same time as the back pain started to migrate up further into your neck.  That's sort of what triggered the headaches?

Appellant: I believe so.  I believe it triggered up from that part, from my back and on up.  I believe that's what triggered it off.  But the pain was moving up, and it comes from that.

Attorney: It sort of starts there, and then will move up into --become a headache?

Appellant: Right.

Attorney: And prior to, you mentioned the last few years --prior to when the neck --when, you know, the back pain kind of became mid-back, and then neck pain, you didn't have any issues with headaches before that, did you?

Appellant: No.

Attorney: Okay.  So, at least in terms of the timeline goes, that's kind of the triggering event?

Appellant: Right.

In review of the hearing testimony, the contention for these claims is understood to be that they are secondary to the service-connected low back disability.  The appellant is competent to report as to the location of his pain.  See 38 C.F.R. � 3.159(a)(1), (2) (defining competent medical and competent lay evidence).  In his testimony, essentially, the appellant reported that his back pain progressed to include neck pain and headaches.  This competent report is found sufficient to satisfy the low threshold to indicate that the claimed neck disability and headaches may be associated with the service-connected low back disability.  As such, the criteria have been met for VA examinations and secondary service connection opinions for these claims, as outlined further in the remand directives below.  See 38 U.S.C. � 5103A(d); 38 C.F.R. � 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006)

Entitlement to Service Connection for OSA

Remand is warranted for to afford the appellant a VA examination and obtain a VA opinion (which was not previously conducted/obtained).

At the May 2022 Board hearing, the appellant's attorney stated that "weight gain being a major factor in the development of sleep apnea.  Should some of these issues get granted, or even on the basis of the back, that's pretty handily causing a lot of issues on its own, I think that that certainly warrants consideration, as well.  Not to mention the mental health."

This statement is understood to raise the issue of secondary service connection for OSA with obesity as the intermediate step to a service-connected low back disability or an acquired psychiatric disability.  Related to this contention are medical records.  See VA Treatment Records, April 2021 (a nutrition note, from a dietitian, noting "[s]tates that his pain in his back and knees keeps him from being too active" and containing a diagnosis of "[p]hysical inactivity related to pain as evidenced by a BMI of 38 and self-statement that his pain limits his ability to be physically active"), August 2021 and April 2022 (including substantively the same statement about physical inactivity related to pain); Back Conditions DBQ, July 2022 (Appellant "reports constant daily pain in the back and is unable to participate in physical activities"); see also Garner v. Tran, 33 Vet. App. 241, 248 (2021) ("considerations that could give rise to a reasonably raised theory of secondary service connection with obesity as an intermediate step may include, but are not limited to, mobility limitations or reduced physical activity as a result of a service-connected physical disability (in particular, orthopedic conditions or chronically painful conditions)").

As background, a relevant precedential VA General Counsel opinion addressing secondary service connection and obesity is VAOPGCPREC 1-2017.  This opinion is binding on the Board.  See 38 U.S.C. � 7104(c) ("The Board shall be bound in its decisions by...the precedent opinions of the chief legal officer of the Department").

VAOPGCPREC 1-2017 held that "[o]besity may be an 'intermediate step' between a service-connected disability and a current disability that may be service connected on a secondary basis."  The opinion addressed a hypothetical of "whether a veteran could establish entitlement to service connection for hypertension if a veteran's service-connected back disability causes obesity due to lack of exercise, which leads to hypertension."  The opinion stated regarding this hypothetical that:

adjudicators would have to resolve the following issues: (1) whether the service-connected back disability caused the veteran to become obese; (2) if so, whether the obesity as a result of the service-connected disability was a substantial factor in causing hypertension; and (3) whether the hypertension would not have occurred but for obesity caused by the service-connected back disability.  If these questions are answered in the affirmative, the hypertension may be service connected on a secondary basis.

The Court addressed VAOPGCPREC 1-2017 in Walsh v. Wilkie, 32 Vet. App. 300 (2020) and indicated that service connection may also be granted based on secondary service connection aggravation involving obesity as an intermediate step.  See Walsh v. Wilkie, 32 Vet. App. 300, 307 (2020) ("to be clear: Despite [VAOPGCPREC 1-2017's] silence regarding aggravation, the Board, in accordance with � 3.310(b), must consider aggravation in this context when the theory is explicitly raised by the veteran or reasonably raised by the record").  The Court provided the framework for the issues to be resolved in this situation by substituting aggravation for causation in the hypothetical addressed by VAOPGCPREC 1-2017, specifically stating "(1) whether the service-connected back disability aggravated the veteran's obesity; (2) if so, whether the aggravation of obesity as a result of service-connected disability was a substantial factor in causing hypertension; and (3) whether the hypertension would have occurred but for obesity aggravated by the service-connected back disability."

In review, given the medical issues raised by the contention of obesity as an intermediate step, along with the related medical records cited above, the criteria have been met for a VA examination and secondary service connection opinion, as outlined further in the remand directives below.  See 38 U.S.C. � 5103A(d); 38 C.F.R. � 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006).

Entitlement to Service Connection for a Right Knee Disability

Entitlement to Service Connection for a Left Knee Disability

Entitlement to Service Connection for a Right Hand Disability

Entitlement to Service Connection for a Left Hand Disability

Entitlement to Service Connection for a Right Wrist Disability, to include CTS

Entitlement to Service Connection for a Left Wrist Disability, to include CTS

Remand is warranted for these claims to afford the appellant a VA examination and obtain a VA opinion (which were not previously conducted/obtained).

At the May 2022 Board hearing, it was contended, essentially, that the claimed disabilities are due to the physical nature of the appellant's active service.  In this regard, the following dialogue (edited for relevancy) occurred at the May 2022 Board hearing between the appellant and his attorney:

Attorney: a lot of, if not maybe most of our musculoskeletal conditions --the knees and the hands and the wrists --these are, in your mind, sort of related to all of the repetitive lifting that you had to do through your MOS?  You know, loading rounds, carrying rounds, carrying the artillery, things like that.  Give us a rundown of what, you know, maybe an average day was like for you when you were in service, and you were lifting all of these things.

Appellant: Yes.  Well, on that, on lifting them rounds, that was --them rounds like 100, 200 pounds.  I was in the field, out there in field artillery.  I was loading them...That's what I was on, 109 tanks, and we was loading these rounds.  They was like 105, 200 pound rounds.  You had to pick them up from the floor up.  And, you know, they would make your --your knees were buckling, and we had to pick them up from the floor up, and load them up.

Attorney: How many of these rounds would you say, on an average day, that you were lifting?

Appellant: Oh, we was doing about 100 to 200 a day.  That's day and night.

Attorney: you mentioned specifically the knees buckling.  Were you hurting during that, and just sort of, you know, knew that this was part and parcel of what you were doing, and kind of just fought through it?

Appellant: Yes.  I was hurting.

Attorney: But the idea of it was, you know, you're loading 100-plus pound rounds whenever you're doing these missions, and you're bending, lifting, over and over and over and over and over, multiple times a day.  And you started to --you know, you sort of felt the cumulative efforts of that, or the cumulative effects of that.  And is it something that sort of as the years went on, you know, some minor nagging pains turned into more life-changing pain?

Appellant: Yes, it did.  But, you know, that was a mission, a job, something.  That was the MOS I was in.  It was something I had to do.  You know?  I was at a position that I had to do.

Attorney: And after you separated, did you continuously experience pain in the knees all the way forward, until today?

Appellant: Right.  Yes.

With respect to the claimed bilateral hand and wrist disabilities, the attorney also stated "a lot of our orthopedic or musculoskeletal conditions all sort of stem from the same, I guess etiology, being [the appellant's] MOS as cannon crew member, and specifically the repetitive motions of loading rounds" and "I would note that some of the hand and wrist conditions that we're talking about are carpal tunnel, which is, you know, obviously notably a repetitive motion type condition or type injury."  The following dialogue also occurred:

Attorney: we're focused right now a little bit on the knees, but you've mentioned the repetitive lifting and carrying and all of that.  And when we talked last week, or thereabouts, you sort of said that was the beginning of all of this.  That was the beginning of the knees, the hands, the wrists.  Obviously, if you're carrying these big, heavy rounds, it's causing a lot of strain on the upper body, as well.  It's not something that's isolated to the lower body.  Is it fair to say that these other conditions followed the same path as the knees?  That you had the minor --you know, relatively minor aches and pains, but you shook them off and you did your duty, what you signed up to do, but it caught up with you down the road, as time went by?

Appellant: Yes, sir.  I really do.

In review of the hearing testimony, the contention for these claims is understood to be that they the claimed disabilities are due to the physical nature of his active service.  The appellant is competent to report as to the physical nature of his service and his DD 214 noted a primary specialty of Cannon Crewman.  The appellant's competent report is found sufficient to satisfy the low threshold to indicate that the claimed disabilities may be associated with his active service.  As such, the criteria have been met for VA examinations and direct service connection opinions for these claims, as outlined further in the remand directives below.  See 38 U.S.C. � 5103A(d); 38 C.F.R. � 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006)

Entitlement to Service Connection for Erectile Dysfunction

Remand is warranted for this claim to obtain a VA opinion.  Previously, the appellant was afforded a VA examination in July 2017, with a Male Reproductive System Conditions DBQ completed, and a direct service connection was obtained.  Subsequently, at the May 2022 Board hearing, the appellant's attorney specifically raised the issue of secondary service connection by stating:

this is an issue that I think is going to be certainly on a secondary basis to any number of these conditions, but particularly the mental health.  Some of the cardiovascular should maybe service connect it, or of course just chronic pain, and the back, as well as [the appellant] has testified today that there are some neurological symptoms, nerve pain involving the back.  Whether or to what degree that has impacted the [erectile dysfunction], I think is certainly more of a medical question than it is anything else.

The appellant previously was service connected for a low back disability and this decision has granted service connection for an acquired psychiatric disability and also bilateral lower extremity radiculopathy.  Given that VA has obtained an opinion as part of this claim previously, and that the contentions regarding secondary service connection raise medical issues the Board is not competent to address, remand is warranted to obtain a VA opinion addressing secondary service connection, as outlined further in the remand directives below.  Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

Increased Initial Rating for a Low Back Disability in excess of 20 Percent

Further specific development regarding this claim is not warranted at this time, but the claim is listed in an effort to be clear about the issues being remanded.

Entitlement to a TDIU

A claim for a TDIU is part of an increased rating claim when such a claim is expressly raised by a veteran or reasonably raised by the record.  See Rice v. Shinseki, 22 Vet. App. 447 (2009).

A May 2021 VA medical record from clinical psychologist S.S. stated that the appellant "identified his primary pain location as low back" and also that "[o]nset of depression began in 2010 in the context of health issues, worsening pain-related impairment, and having to retire early due to pain."  This statement indicated that the appellant's pain, with his primary pain location being identified as his low back, caused him to retire early.  This record is found to be sufficient to raise the issue of entitlement to a TDIU.

In review, the issue of entitlement to a TDIU is found to be reasonably raised by the record and part of the appeal before the Board.  Remand is warranted for this claim, as it is inextricably intertwined with the development previously discussed, to include obtaining outstanding records.  In addition, the AOJ did not directly adjudicate the issue of entitlement to a TDIU and, therefore, any appropriate development related to this issue has not been conducted.  Remand is also warranted for any such development deemed warranted, which is found at this time to include requesting that the appellant complete VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability).

Entitlement to SMC Based on Aid and Attendance pursuant to 38 U.S.C. � 1114(l)

While the appellant has not specifically claimed entitlement to SMC, it is found to be reasonably raised by the evidence of record and, as such, it is properly before the Board at this time.  See Bradley v. Peake, 22 Vet. App. 280, 294 (2008) (stating that SMC benefits "are to be accorded when a veteran becomes eligible without need for a separate claim.  See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991)"); see also 38 C.F.R. � 3.155(d)(2) ("Scope of claim. Once VA receives a complete claim, VA will adjudicate as part of the claim entitlement to any ancillary benefits that arise as a result of the adjudication decision (e.g., entitlement to [SMC] under 38 C.F.R. � 3.350").

SMC based on aid and attendance pursuant to 38 U.S.C. � 1114(l) is warranted when "as the result of service-connected disability... [the appellant is] with such significant disabilities as to be in need of regular aid and attendance."  38 C.F.R. � 3.352(a) provides basic criteria for aid and attendance, to include consideration of an inability of a claimant to dress or undress himself or to keep himself ordinarily clean and presentable.

At the May 2022 Board hearing, the appellant's daughter-in-law testified that "he feels when it comes time for him to do something or he wants to do something, he can't do it on his own, so he hates for us to have to do it for him all the time, far as his daily activities" and "[s]ometimes when it comes to putting on his shoes, taking him places, doing stuff, showers, he needs help with most of that stuff due to the pain management."

As discussed above, following the Board hearing, the appellant submitted a private Back Conditions DBQ, completed in June 2022 by Dr. R.L.  Diagnoses were noted of lumbosacral strain and radiculopathy.  Dr. R.L. stated "[c]ondition prevents [appellant] from performing personal hygiene, dressing, and lifting objects without needing assistance" and also "[c]ondition prevents [appellant] from performing household chores and hinders the ability to change clothes, perform personal grooming needs, and place shoes on at time."

In review, the issue of entitlement to SMC based on aid and attendance pursuant to 38 U.S.C. � 1114(l) is found to be reasonably raised by the record and part of the appeal before the Board.  Remand is warranted for this claim, as it is inextricably intertwined with the development previously discussed, to include obtaining outstanding records.  In addition, the AOJ did not directly adjudicate the issue of entitlement to SMC and, therefore, any appropriate development related to this issue has not been conducted.  Remand is also warranted for any such development deemed warranted, which is found at this time to include a specific SMC examination and completion of VA Form 21-2680 (Examination for Housebound Status or Permanent Need for Regular Aid and Attendance).

The matters are REMANDED for the following action:

1. Attempt to obtain any SSA disability records available.

2. Obtain all outstanding VA treatment records from July 2022.

3. Obtain an opinion from a medical professional that addresses the appellant's hypertension claim.  If the medical professional determines that additional examination of the appellant is necessary to provide an adequate opinion, such examination must be scheduled.

The medical professional must provide an opinion addressing the following:

Whether it is likely (an approximate balance of the positive and negative evidence) that the appellant's hypertension had its onset during service, within one year of discharge from service, or is otherwise related to service.

The medical professional's attention is invited to:

(a.) That the appellant has been diagnosed with hypertension.  See Hypertension DBQ, July 2017.

(b.) An August 1980 STR (during active service) that contained an elevated blood pressure reading of 150/110.

(c.) A post active service May 1982 Reserve examination report, which was conducted within one year of the appellant's separation from active service in July 1981.  This examination report included an elevated blood pressure reading of 130/98.  A diagnosis was listed of "[e]levated blood pressure - instructed by doctor have follow-up with family physician."

(d.) The appellant's contention "that he did follow up with a primary care provider, and was treating for hypertension for all these years.  It just so happens that those records are 40 years old at this point, and don't exist anymore."  See Board Hearing Transcript, May 2022, Page 5.

(e.) The July 2017 Hypertension DBQ that noted a date of diagnosis of "1980's," noted under the medical history section a date of onset of "1980's" and that "[i]n the early 1980's he was diagnosed as having hypertension during a routine US Army office visit."

The course since onset was noted as persistent.

(f.) A post active service May 1985 Reserve STR, specifically a Health Questionnaire for Dental Treatment (DA Form 5570), where the appellant reported taking medication for high blood pressure.

4. Obtain an opinion from a medical professional that addresses the appellant's right and left foot disability claims.  If the medical professional determines that additional examination of the appellant is necessary to provide an adequate opinion, such examination must be scheduled.

The medical professional must provide an opinion addressing the following:

Whether it is likely (an approximate balance of the positive and negative evidence) that any left or right disability is caused by, or is related to, service.

The medical professional's attention is invited to:

(a.) That the appellant has been diagnosed with bilateral pes planus.  See Foot Conditions DBQ, July 2017.

(b.) The July 2017 Foot Conditions DBQ that noted a date of diagnosis of 1979, noted under the medical history section a date of onset of "1980's" and that "[h]e began having symptoms of flat feet back in 1979.  He says that the constant training and exercising that was required caused this problem to occur.  He would have to walk at least three or more miles.  He had to walk with his full Army gear including his helmet rucksack in excess of 50 pounds and his weapons.  At the end of this walk or run he states that his feet were hurting. His foot pain was relieved with resting."

The course since onset was noted as "has become worse."

(c.) The appellant's May 2022 Board hearing testimony, that, essentially, foot issues/pain started during in-service road marches while wearing combat boots and carrying gear and that he pushed through this.  See Board Hearing Transcript, May 2022, Pages 17-19.

5. Afford the appellant a VA examination with respect to his bilateral hearing loss disability claim.

The clinician must provide an opinion addressing the following:

Whether it is likely (an approximate balance of the positive and negative evidence) that a bilateral hearing loss disability is caused by, or is related to, service.

The clinician's attention is invited to:

(a.) That the AOJ conceded that the appellant had a high probability of exposure to hazardous noise.  See Statement of the Case, March 2020 ("VA conceded a high probability of exposure to hazardous noise based on your military occupation of Cannon Crewman").

(b.) The appellant's May 2022 Board hearing testimony, that, essentially, described his in-service exposure to loud noises, to include shooting tanks in live fire exercises without earplugs.  See Board Hearing Transcript, May 2022, Page 23.

(c.) The appellant's report that in his post-service employment, he was required to wear hearing protection.  See Board Hearing Transcript, May 2022, Page 26.

(d.) Exams from the appellant's Reserve service, which showed some degree of hearing loss.  Hensley v. Brown, 5 Vet. App. 155, 157 (1993) ("the threshold for normal hearing is from 0 to 20 dB, and higher threshold levels indicate some degree of hearing loss"). Specifically:

i.	A January 1983 Reserve Report of Medical Examination noted 25 decibels (dB) at 6000 Hertz (Hz) for the right ear;

ii.	A June 1986 Reserve Report of Medical Examination noted 25 dB at 4000 Hz for the left ear; and

iii.	A September 1990 Reserve Report of Medical Examination noted 25 dB at 500 Hz for the right ear and 30 dB at 4000 Hz for the left ear.

(e.) A contention from the appellant's attorney at the May 2022 Board hearing regarding a threshold shift for the right ear at 6000 Hz from 5 dB shown on an in-service July 1980 STR compared to 20 dB at 6000 Hz shown on a post-service May 1982 Report of Medical Examination.  See Board Hearing Transcript, May 2022, Page 5.

While not contended, a similar shift occurred for the left ear at 6000 Hz from 5 dB shown on the February 1979 Report of Medical Examination compared to 20 dB at 6000 Hz shown on a July 1980 STR.

6. Afford the appellant a VA examination with respect to his (1) neck disability and (2) headaches claims.

The clinician must provide an opinion addressing the following:

(a.) Whether it is likely (an approximate balance of the positive and negative evidence) that any (1) neck disability or (2) headaches are due to or caused by the appellant's service-connected low back disability (lumbosacral strain).

(b.) Whether it is likely (an approximate balance of the positive and negative evidence) that any (1) neck disability or (2) headaches have been aggravated (i.e., increased in severity) by the appellant's service-connected low back disability (lumbosacral strain).

The clinician's attention is invited to:

(a.) VA treatment records noting a neck disability and headaches.  See VA Treatment Record, March 2022 (noting a diagnosis of chronic neck pain secondary to degenerative disc disease (DDD) and including headache on the active problem list).

(b.) The contention that, essentially, a neck disability and headaches are secondary to the service-connected low back disability because back pain progressed to include neck pain and headaches.  See Board Hearing Transcript, May 2022, Pages 12-15 (neck disability), 19 (headaches).

7. Afford the appellant a VA examination with respect to his OSA claim.

The clinician must provide an opinion addressing the following:

(a.) Whether it is likely (an approximate balance of the positive and negative evidence) that the appellant's service-connected low back disability (lumbosacral strain) or acquired psychiatric disorder (to include somatic symptom disorder, major depressive disorder or generalized anxiety disorder) caused the appellant to become obese.

(b.) Whether it is likely (an approximate balance of the positive and negative evidence) that the appellant's service-connected low back disability or acquired psychiatric disorder aggravated the appellant's obesity.

If, and only if, a positive opinion is provided as to either "a" or "b," the medical professional must provide an opinion addressing the following:

(c.) Whether it is likely (an approximate balance of the positive and negative evidence) that the obesity, or aggravation of obesity, as a result of the service-connected low back disability or acquired psychiatric disorder was a substantial factor in causing the appellant's OSA.

(d.) If so, whether the appellant's OSA would have not occurred but for obesity caused, or aggravated by, the service-connected low back disability or acquired psychiatric disorder.

The medical professional's attention is invited to:

(a.) That the appellant has been diagnosis with OSA.  See VA Treatment Records, January 2022 (pulmonary note with a diagnosis of OSA), May 2011 (noting a diagnosis of OSA following a sleep study).

(b.) Medical records discussing the impact of the appellant's back pain on his ability to participate in physical activities.  See VA Treatment Records, April 2021 (a nutrition note, from a dietitian, noting "[s]tates that his pain in his back and knees keeps him from being too active" and containing a diagnosis of "[p]hysical inactivity related to pain as evidenced by a BMI of 38 and self-statement that his pain limits his ability to be physically active"), August 2021 and April 2022 (including substantively the same statement about physical inactivity related to pain); Back Conditions DBQ, July 2022 (Appellant "reports constant daily pain in the back and is unable to participate in physical activities").

8. Afford the appellant a VA examination with respect to his (1) right knee disability, (2) left knee disability, (3) right hand disability, (4) left hand disability, (5) right wrist disability and (6) left wrist disability claims.

The clinician must provide an opinion addressing the following:

Whether it is likely (an approximate balance of the positive and negative evidence) that any (1) right knee disability, (2) left knee disability, (3) right hand disability, (4) left hand disability, (5) right wrist disability and (6) left wrist disability is caused by, or is related to, service.

The clinician's attention is invited to:

(a.) VA treatment records reflecting a diagnoses related to the claim disabilities.  See VA Treatment Record, March 2022 (noting a diagnosis of bilateral knee pain secondary to severe degenerative joint disease and including carpal tunnel syndrome on the active problem list), September 2018 (a surgical note for right wrist carap tunnel release), October 2012 (a surgical note for left wrist carpal tunnel release).

(b.) The contention that, essentially, the claimed disabilities are due to the physical nature of the appellant's active service.  See Board Hearing Transcript, May 2022, Pages 3, 14-17.

(c.) The contention that, essentially, the appellant experienced knee symptoms in service and pain since active service.  See Board Hearing Transcript, May 2022, Pages 14-16 (reporting his "knees buckling" and that he "was hurting" during active service and also answering yes to a question of "after you separated, did you continuously experience pain in the knees all the way forward, until today?").

(d.) The contention that the claimed right hand disability, left hand disability, right wrist disability and left wrist disability "followed the same path as the knees...That you had the minor --you know, relatively minor aches and pains, but you shook them off and you did your duty, what you signed up to do, but it caught up with you down the road, as time went by."  See Board Hearing Transcript, May 2022, Pages 16-17.

9. Obtain an opinion from a medical professional that addresses the appellant's erectile dysfunction claim.  If the medical professional determines that additional examination of the appellant is necessary to provide an adequate opinion, such examination must be scheduled.

The medical professional must provide an opinion addressing the following:

(a.) Whether it is likely (an approximate balance of the positive and negative evidence) that the appellant's erectile dysfunction is due to or caused by a service-connected low back disability (lumbosacral strain), bilateral lower extremity radiculopathy or an acquired psychiatric disorder (to include somatic symptom disorder, major depressive disorder or generalized anxiety disorder).

(b.) Whether it is likely (an approximate balance of the positive and negative evidence) that the appellant's erectile dysfunction has been aggravated (i.e., increased in severity) by a service-connected low back disability, bilateral lower extremity radiculopathy or an acquired psychiatric disorder.

The medical professional's attention is invited to:

(a.) That the appellant has been diagnosis with erectile dysfunction.  See, e.g., Male Reproductive Systems DBQ, July 2017.

(b.) VA treatment records noting that pain impacted/interfered with the appellant's sexual functioning.  See VA Treatment Records, March 2021 ("with chronic low back pain.  His chronic pain appears to negatively impact all life domains including his... sexual functioning"), May 2021 ("identified his primary pain location as low back with onset more than 30 years ago...endorsed current pain-related interference in all domains, including...sexual functioning").

10. Provide the appellant with VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) and request that he supply the requisite information.  Conduct any further development of the TDIU claim deemed necessary.

11. Afford the appellant a VA examination as to his claim for SMC based on aid and attendance pursuant to 38 U.S.C. � 1114(l) and complete VA Form 21-2680.  Conduct any further development of the SMC claim deemed necessary.

For all opinions provided, the medical professional must include the underlying reasons for any conclusions reached.

The Board does not make any credibility determinations at this time with respect to the appellant's lay statements.

12. Thereafter, readjudicate the claims.

K.A. KENNERLY

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S. Hoopengardner, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. � 20.1303.