DEGENERATIVE ARTHRITIS OF THE SPINE (SPONDYLOSIS)

NATHANIEL DOAN · 2026 · Case ID: 26005102

MIXED

Summary

The veteran, who served in the Army from July 1976 to December 1976, appeals the denial of service connection for several conditions and the grant of TDIU. The Board granted service connection for lumbar degenerative arthritis and degenerative disc disease, finding the veteran's in-service injury reports and the lack of service treatment records (STRs) probative, despite inadequate VA examiner opinions. Service connection for left knee osteoarthritis was also granted based on similar reasoning. For eye conditions (glaucoma, dry eye syndrome, cataracts), the Board found them aggravated by the service-connected PTSD, overturning multiple negative VA opinions that relied on age and general risk factors, and instead favoring a later VA opinion that linked stress hormones to optic nerve damage. The Board granted TDIU from September 28, 2009, based on the veteran's service-connected PTSD, noting his inability to secure substantially gainful employment due to psychiatric symptoms, intermittent homelessness, and lack of earned income throughout the appeal period. The case was remanded for further development regarding entitlement to special monthly compensation (SMC) based on aid and attendance, due to missing home health records. Additionally, claims for coronary artery disease, diabetes mellitus type II, residuals of stroke, and obstructive sleep apnea were remanded for adequate addendum opinions on secondary service connection, specifically addressing whether service-connected PTSD, back, or knee disabilities caused or aggravated obesity, and whether that obesity substantially contributed to these conditions.

Rationale

Veteran reported in-service injury and treatment for back; STRs unavailable, despite multiple attempts to locate; Inadequate VA examiner opinions that did not consider lay statements or provide adequate rationales

Service Branch

ARMY

Special Benefit

SMC - AID & ATTENDANCE; TDIU

Docket No.

11-15 409

Full Decision Text

Citation Nr: 26005102
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 11-15 409
DATE: April 30, 2026

ORDER

Service connection for lumbar degenerative arthritis and degenerative disc disease is granted.

Service connection for left knee osteoarthritis is granted.

Service connection for eye disorder, diagnosed as glaucoma, dry eye syndrome, and cataracts is granted.

A total rating based on individual unemployability due to service-connected PTSD from September 28, 2009, is granted.

REMANDED

Entitlement to special monthly compensation based on aid and attendance is remanded.

Entitlement to service connection for coronary artery disease is remanded.

Entitlement to service connection for diabetes mellitus, type II, is remanded.

Entitlement to service connection for residuals of stroke is remanded.

Entitlement to service connection for obstructive sleep apnea is remanded.

FINDINGS OF FACT

1. The Veteran's current lumbar degenerative arthritis and degenerative disc disease had its onset in service.

2. The Veteran's current left knee osteoarthritis had its onset in service.

3. The Veteran's bilateral glaucoma, bilateral cataracts, and bilateral dry eye syndrome are aggravated by his service-connected PTSD.

4. The Veteran's service-connected PTSD rendered him unable to secure or follow a substantially gainful occupation consistent with his education and work history from September 28, 2009.

CONCLUSIONS OF LAW

1. The criteria for service connection for lumbar degenerative arthritis and degenerative disc disease have been met. 38?U.S.C. §§?1110, 5107; 38?C.F.R. §§?3.102, 3.303, 3.307, 3.309.

2. The criteria for service connection for left knee osteoarthritis have been met. 38?U.S.C. §§?1110, 5107; 38?C.F.R. §§?3.102, 3.303, 3.307, 3.309.

3. The criteria for service connection for bilateral glaucoma, bilateral cataracts, and bilateral dry eye syndrome have been met. 38 U.S.C. §§ 1110, 5103; 5107; 38 C.F.R. §§ 3.159, 3.303, 3.310.

4. From September 28, 2009, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from July 1976 to December 1976.

These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in March 2009 and October 2010 by a Department of Veterans Affairs (VA) regional office, the agency of original jurisdiction (AOJ).

The Board remanded these matters for additional development in September 2015, December 2020 and May 2022. The appeal is now returned to the Board for further appellate consideration.

Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service.?38?C.F.R. §?3.303(a). Service connection may also 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.? 38?C.F.R. §?3.303(d).?Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7?Vet. App.?498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996).

Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R.
, 7?Vet. App.?498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996).

Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a), such as arthritis, and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

1. Entitlement to service connection for lumbar degenerative arthritis and degenerative disc disease.

2. Entitlement to service connection for left knee osteoarthritis.

The Veteran contends that he is entitled to service connection for his back and left leg disorders. In this regard, the Veteran asserts that he injured both in service and was treated for both in service. The Board notes that the record reflects that the Veteran's service treatment records (STRs) are not available for review, despite multiple attempts to locate them.

August 2019 VA treatment records reflect the Veteran's report of left knee and low back pain. VA treatment records reflect diagnoses of lumbar degenerative disc disease (also known as degenerative joint disease) and left knee osteoarthritis. The August 2021 VA examination for the back also reflects diagnoses of degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (IVDS), and lumbosacral strain. Accordingly, the Board finds that the first element of service connection, a current disability is met for each of these claims.

With regard to the second element of service connection, the Board finds that the Veteran's report of an in-service injury to and in-service treatment for his back and left knee are probative. In this regard, in March 2010 VA treatment records the Veteran reported such, as well as indicating such in a June 2010 written statement. The Board finds the Veteran credible and competent to report his experience sustaining an injury in service. Moreover, the Board again acknowledges the VA's inability to locate the Veteran's STRs. Accordingly, the Board finds that the second element of service connection is met for each of these claims.

Upon VA examination in August 2021, the Veteran reported that his back pain started a "long time ago due to back injury." Further, the Veteran has asserted multiple times throughout the record, including the June 2010 written statement, that his left leg pain started after his injury in service and has continued since.

The Board acknowledges that the record contains multiple opinions from various VA examiners pertaining to the etiology of the Veteran's lumbar and left leg disabilities. All such opinions opine that the Veteran's disabilities are not due to service; however, such are inadequate as they do not consider the Veteran's lay statements, rely on the lack of STRs in the record, rely on the lack of documented chronicity in the
.

Moreover, the Veteran is competent to report the onset and continuation of his low back and left knee pain. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 31 Vet. App. 303, 307-08 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 470 (1994).

Accordingly, the Board finds that service connection is warranted for lumbar degenerative arthritis and degenerative disc disease and left knee osteoarthritis. 38 C.F.R. §§ 3.307, 3.309.

3. Entitlement to service connection for eye disorder, diagnosed as glaucoma, dry eye syndrome, and cataracts.

The Veteran contends that his eye disorders are secondary to his service-connected psychiatric disability.

VA treatment records reflect an August 2018 diagnosis of dry eye syndrome and upon VA examination in July 2021, the Veteran's diagnoses of glaucoma and cataracts were noted. Accordingly, the Board finds that the first element of service connection, a current disability, is met.

Accordingly, the remaining inquiry before the Board is whether such current disability was either proximately caused by or proximately aggravated by a service-connected disability. The Board has carefully reviewed the record and finds that the Veteran's diagnosed eye disabilities were aggravated by his service-connected psychiatric disability.

In this regard, upon VA examination in July 2021, the VA examiner identified the Veteran's bilateral glaucoma and bilateral cataract. The Veteran reported that the onset of his current disability was blurry vision and light sensitivity.

In July 2021, the VA examiner opined that the Veteran's glaucoma is less likely than not incurred in or caused by service. In support of such, the examiner explained that risk factors for glaucoma include age, ethnicity, family history, and other diseases such as diabetes and hypertension. The examiner explained that glaucoma is a major public health problem and is the second most common cause of blindness, after cataracts.

The July 2021 VA examiner also opined that the Veteran's eye disorders are less likely than not proximately due to or the result of the Veteran's service-connected condition. In support of such, the examiner explained that glaucoma is a group of conditions in which there is characteristic cupping of the optic disc with corresponding visual field defects, due to retinal ganglion cell loss, and raised intraocular pressure (IOP). The examiner explained that risk factors include age, ethnicity, family history, and diabetes; and, notably, that there is no pathophysiological connection between glaucoma and an acquired psychiatric disorder.

The examiner explained that cataracts involve nuclear sclerosis, which is the yellowing and hardening of the central portion of the crystalline lens and that such occurs slowly over years. The examiner provided that as the core of the lens hardens, it often causes the lens to increase the refractive power and causes nearsightedness. The examiner explained that risk factors for cataract development include diabetes, steroid use, smoking, ocular diseases, and genetic predisposition.

In June 2022, a different VA examiner reviewed the record and opined that the Veteran's dry eye syndrome, glaucoma, and cataracts are less likely than not incurred or caused by service. In support of such, the examiner explained that dry eye syndrome is a part of the natural aging process. The examiner explained that the majority of people over age 65 experience some symptoms of dry eyes, moreover, the examiner provided that the Veteran is 67 years of age. Accordingly, the examiner indicated that the likely etiology of the Veteran's dry eye syndrome is age, rather than service.

The June 2022 VA
ataract development include diabetes, steroid use, smoking, ocular diseases, and genetic predisposition.

The June 2022 VA examiner also explained that cataracts are a cloudy or opaque area in the normally clear lens of eye that can interfere with vision. The examiner explained that most cataracts occur to people over age 55, and noted the Veteran's age of 67. Specifically, the examiner explained that the Veteran's cataracts were found to occur during the time which is usually associated with the natural aging of the lens; accordingly, such is not due to service.

Finally, the June 2022 VA examiner explained that glaucoma is a group of eye conditions that damage the optic nerve, which is vital for good vision. The examiner explained that glaucoma is one of the leading causes of blindness for people over the age of 60, and that such commonly occurs in older adults. Accordingly, the Veteran's glaucoma is not directly due to service.

In July 2022, another VA examiner opined that the Veteran's 2018 diagnosis of dry eye syndrome was less likely than not incurred in or caused by service. In support of such, the examiner explained that such condition is common and chronic, particularly in older adults. Ultimately, the examiner provided that records do not support any nexus between the Veteran's service and his dry eye syndrome.

The Board finds that the June 2022 and July 2022 VA opinions pertaining to direct service connection have high probative value as they provide an opinion that is specific to the Veteran's circumstances and provide an adequate rationale.

In April 2024, the VA examiner opined that the Veteran's glaucoma, cataracts, and dry eye syndrome are less likely than not due to or the result of the Veteran's service-connected condition. In support of such, the examiner explained the process of each disease and the risk factors, but did not indicate which risk factors are pertinent in the Veteran's situation. The examiner also stated that PTSD is not an established risk factor for developing any of the three claimed eye disorders, without providing any support for such statement.

In August 2024, the VA examiner opined that stress and anxiety are known risk factors for eye disorders such as glaucoma, cataracts, and dry eye syndrome. The examiner opined that the Veteran's PTSD and chronic stress can significantly affect the eyes and elevated stress hormones over time worsen the conditions beyond their normal progression. The examiner provided a thorough rationale explaining the relationship between stress and the eyes, including that stress over time can lead to optic nerve damage, supporting the opinion that the Veteran's eye disorders are aggravated by his PTSD.

The Board finds the August 2024 opinion highly probative with regard to the Veteran's PTSD aggravating his diagnosed eye disorders.

In September 2024, the AOJ obtained a clarification opinion regarding the positive aggravation opinion and that VA examiner indicated that the Veteran's PTSD did not aggravate any eye disorder. In support of such, the examiner provided a conclusory rationale. In May 2025, the VA examiner provided additional rationale supporting his negative opinion, primarily relying on the lack of medical evidence to suggest glaucoma was made directly made worse by the Veteran's PTSD. He addresses the Veteran's lay statement but dismisses it by stating that the Veteran's glaucoma "may have progressed" in the absence of PTSD. The Board finds such opinion is speculative and does not provide an adequate rationale.

Again, the Board finds that the August 2024 VA examiner's opinion has the highest probative value as it provides medical evidence supporting its conclusion and addresses the Veteran's lay statements pertaining to the effect of his PTSD on his eye disorders.

Based on the foregoing, the Board finds that the Veteran's bilateral glaucoma, bilateral cataracts, and bilateral dry eye syndrome are aggravated by service-connected PTSD, and service connection is warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102.

4. Entitlement to TDIU.

The Veteran contends he is entitled to TDIU. In the September 2015, December 202
's opinion has the highest probative value as it provides medical evidence supporting its conclusion and addresses the Veteran's lay statements pertaining to the effect of his PTSD on his eye disorders.

4. Entitlement to TDIU.

The Veteran contends he is entitled to TDIU. In the September 2015, December 2020, and May 2022 Board remands, the Board directed the AOJ to develop and adjudicate the Veteran's claim for TDIU as the Board found that such has been reasonably raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009).

The Board observes that from March 18, 2024, the Veteran is in receipt of a 100 percent rating for PTSD with unspecified depressive disorder. Generally, total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). However, a 100 percent disability rating does not always render the issue of a TDIU moot. VA's duty to maximize a claimant's benefits includes consideration of whether his disabilities establish entitlement to SMC pursuant to 38 C.F.R. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011).

"Substantially gainful employment" is considered "work that involves doing significant productive physical or mental duties and is done for pay or profit" even if the work "is done on a part-time basis or if a claimant is paid less or is given less responsibility than when the same claimant worked before." In other words, a "substantially gainful occupation" is "one that provides annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that the veteran actually works and without regard to the veteran's earned annual income" prior to when he was last employed. See Faust v. West, 13 Vet. App. 342, 356 (2000) (citing analogous Social Security Administration regulations).

Marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. 38 C.F.R. § 4.16(a). Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims regarding the nature of the employment and the reason for termination. Id.

Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 42 Vet. App. 447, 452 (2009). Therefore, when adjudicating a TDIU claim, VA must consider the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 31 Vet. App. 356 (1991) (considering Veteran's master's degree in education and his part-time work as a tutor).

Age may not be considered as a factor when evaluating unemployability or inter
); Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 31 Vet. App. 356 (1991) (considering Veteran's master's degree in education and his part-time work as a tutor).

Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993).

In Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court defined the term "unable to secure and follow a substantially gainful occupation" in § 4.16(b) to include two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of the veteran's history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue.

During the pendency of the appeal, from September 28, 2009, the Veteran is service connected for PTSD with unspecified depressive disorder, rated 50 percent disabling and 100 percent disabling from March 18, 2024. From July 27, 2018, the Veteran is also service-connected for tinnitus, rated 10 percent disabling. The Board granted service connection for lumbar degenerative arthritis and degenerative disc disease, left knee osteoarthritis, as well as for bilateral glaucoma, bilateral cataract, and bilateral dry eye syndrome; however, as the AOJ has not yet effectuated such grants, the disability ratings for such disabilities are unknown. However, the Board will consider whether the Veteran is entitled to TDIU due to service connected PTSD alone, as this has been service-connected through the appeal period. See Witkowski v. Collins, No. 24-0640, 2025 LX 495001 (Vet. App. Oct. 21, 2025).

As previously indicated, the Board remanded this matter in September 2015, December 2020, and May 2022 and directed the AOJ to allow the Veteran to complete VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability. The AOJ provided the Veteran with such opportunity; however, no response was received. Nonetheless, the Board will proceed to the merits of the claim.

The April 2021 VA examination for PTSD reflects that the Veteran did not attend high school and enlisted with the army at age 19. The Veteran was discharged after four months in 1976 and proceeded to serve in the National Guard through 1984. The Veteran reported that he worked as a bobtail truck driver for many years and stopped working in the 1980s. He reported that he did not obtain any additional degrees and was not currently enrolled in school.

Moreover, a review of VA treatment records reflects that the Veteran was intermittently homeless throughout the appeal period, received social security income, and did not receive any earned income. Based on such evidence, the Board finds that the Veteran has not worked during the appeal period.

The July 2021 VA examination report indicates that the Veteran's eye disability impacts his ability to perform occupational tasks. Specifically, it is indicated that the Veteran's condition causes him to have blurry vision that is not correctable to 20/20 and reduced visual fields that impact his ability to perform occupational functioning and ordinary activities.

The August 2021 VA examination report indicates that the Veteran's back disability impacts his
not obtain any additional degrees and was not currently enrolled in school.

The August 2021 VA examination report indicates that the Veteran's back disability impacts his ability to perform occupational tasks. Specifically, it is indicated that the Veteran's weight bearing is limited to 15 minutes at a time, cannot sit for more than 15 minutes, cannot bend, and cannot lift more than ten pounds.

The August 2021 VA examination report reflects that the Veteran's left leg disability impacts his ability to perform occupational tasks, including limited weight bearing, squatting, kneeling, and climbing.

The August 2021 VA examination report of the Veteran's psychiatric disability reflects the Veteran's reports of insomnia, recurrent dreams, intrusive memories, hypervigilance, excessive worrying, and that he was hospitalized for 72 hours about two years prior for suicidal ideation. The examiner indicated that the Veteran's psychiatric symptoms include depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner also noted the Veteran's history of "passive thoughts of death" as well as the Veteran's endorsed symptoms of social avoidance; constricted affect; depression; and anxiety that reportedly interfere with his ability to work collaboratively with others. The examiner also noted that the Veteran's endorsed symptoms of reduced motivation, sleep impairment, depression, and anxiety that reportedly reduce the efficiency with which claimant is able to engage in the physical and sedentary activities of employment.

Based on the foregoing, the Board finds that the Veteran's did not work throughout the entire appeal period; and that from at least September 28, 2009, the Veteran's service-connected PTSD rendered him unable to secure or follow substantially gainful employment. Consequently, a TDIU is warranted from September 28, 2009. This is a complete grant of the benefit sought on appeal as to this issue. When the AOJ effectuates the service connection grants contained in this decision, the AOJ should consider whether the criteria for SMC under 38 U.S.C. § 1114(s) are met.

REASONS FOR REMAND

1. Entitlement to SMC based on aid and attendance.

The Veteran contends that he is entitled to SMC, based on aid and attendance. The Board finds that such issue must be remanded as such is inextricably intertwined with the effectuation of the grants herein and the AOJ has not properly developed the Veteran's claim.

A review of the evidence of record reflects that the Veteran is in receipt of home health services, that may include support for his activities of daily living. Particularly, as directed in the May 2022 Board remand: "Additionally, VA record entries from August 2, 2021, and September 20, 2021, note that home health records had been scanned into VistA Imaging. It does not appear that the referenced records have been associated with the claims file. A remand to obtain the outstanding records is required."

Unfortunately, there has not been substantial compliance with the Board's last remand in this regard and additional remand is required. Stegall v. West, 11 Vet. App. 268 (1998). The AOJ shall obtain such records, associate them with the file, and conduct the appropriate development to determine whether such assistance renders the Veteran's entitled to SMC, aid and attendance.

2. Entitlement to service connection for coronary artery disease (CAD).

3. Entitlement to service connection for diabetes mellitus, type II (diabetes).

4. Entitlement to service connection for residuals of stroke (stroke).

5. Entitlement to service connection for obstructive sleep apnea.

The Veteran contends that his CAD, diabetes, stroke, and sleep apnea are due to his service-connected PTSD with unspecified depressive disorder.

4. Entitlement to service connection for residuals of stroke (stroke).

5. Entitlement to service connection for obstructive sleep apnea.

The Veteran contends that his CAD, diabetes, stroke, and sleep apnea are due to his service-connected PTSD with unspecified depressive disorder.

In this regard, the Board notes that obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). See VAOPGCPREC 1-2017. However, in order to show secondary service connection is warranted under such a theory, a veteran must show (1) that his service-connected disability caused or aggravated his obesity and, if so, (2) whether the obesity as a result of the service-connected disability was a substantial factor in causing or aggravating his claimed condition, and (3) whether the claimed condition would not have occurred or worsened but for obesity caused by the service-connected disability. Id.; Walsh v. Wilkie, 32 Vet. App. 300 (2020).

In developing the Veteran's claim, in May 2024, the AOJ obtained opinions as to whether the Veteran's psychiatric disability caused obesity, and if so, whether such obesity caused or aggravated the claimed condition. However, unfortunately, such opinions are inadequate for adjudication. Notably, the VA examiner provided the very same, verbatim, rationale to support his opinion that the Veteran's psychiatric disability did not "cause limited physical activity which led to the development of obesity" pertaining to the Veteran's claims for CAD, diabetes, stroke, and sleep apnea.

In review of these opinions, such opinion is not reflective of the specifics of the Veteran's circumstances, does not consider the Veteran's lay statements pertaining to the effect of his psychiatric disability on his lifestyle, and does not opine whether the psychiatric disability may have aggravated his obesity. See Bailey v. O'Rourke, 30 Vet. App. 54, 60-61 (2018) (holding that a medical opinion was inadequate as a matter of law because the rationale was based solely on general articles and did not discuss any facts pertaining to Veteran's condition or individual circumstances); Buchanan v. Nicholson, 451 F.3d 1331, 1336, n. 1 (Fed. Cir. 2006) (stating that an examiner's opinion failed to consider whether lay statements presented sufficient evidence of the etiology of the Veteran's disability such that his claim could be proven without contemporaneous medical evidence); El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (stating that a secondary service connection medical opinion was inadequate because it did not discuss aggravation).

Accordingly, the Board finds that remand is necessary in order to obtain adequate addendum opinions addressing such matter. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (when VA undertakes to provide a Veteran with a VA examination or medical opinion, it must be adequate).

Further, given the grants of service connection for the low back disability, left knee, and eye disabilities herein, such disabilities shall be considered by the VA examiner in opining whether the Veteran's service-connected disabilities caused or aggravated his obesity, and if, so, whether such obesity caused or aggravated his claimed conditions.

The matters are REMANDED for the following action:

1. Obtain the VistA Imaging records referenced in the August 2, 2021, and September 20, 2021, VA record entries. If any requested records are unavailable, the Veteran should be notified of such.

2. After completing directive #1, develop the Veteran's claim for SMC based on aid and attendance.

3. Forward the record, to include a copy of this Remand, to an appropriate clinician other than the clinician who provided the May 2024 opinions for an addendum opinion addressing the etiology of the Veteran's CAD, diabetes, residuals of stroke, and obstructive sleep apnea.

After a review of the record, the clinician should address the following inquiries:

(a.) is it approximately at least as likely as not that the Veteran's service-connected PTSD, back disability, and/or left knee disability, to include medications taken for such disabilities, caused or aggravated his obesity and, if so, (2) whether such resulting obesity was a substantial factor in causing or aggravating his CAD and (3) whether his CAD would not have occurred or worsened but for the obesity caused by such service-connected disability or disabilities;

After a review of the record, the clinician should address the following inquiries:

(b.) is it approximately at least as likely as not that the Veteran's service-connected PTSD, back disability, and/or left knee disability, to include medications taken for such disabilities, caused or aggravated his obesity and, if so, (2) whether such resulting obesity was a substantial factor in causing or aggravating his diabetes and (3) whether his diabetes would not have occurred or worsened but for the obesity caused by such service-connected disability or disabilities.

(c.) is it approximately at least as likely as not that the Veteran's service-connected PTSD, back disability, and/or left knee disability, to include medications taken for such disabilities, caused or aggravated his obesity and, if so, (2) whether such resulting obesity was a substantial factor in causing or aggravating his stroke residuals and (3) whether his stroke residuals would not have occurred or worsened but for the obesity caused by such service-connected disability or disabilities.

(d.) is it approximately at least as likely as not that the Veteran's service-connected PTSD, back disability, and/or left knee disability, to include medications taken for such disabilities, caused or aggravated his obesity and, if so, (2) whether such resulting obesity was a substantial factor in causing or aggravating his obstructive sleep apnea and (3) whether his obstructive sleep apnea would not have occurred or worsened but for the obesity caused by such service-connected disability or disabilities.

A rationale shall be provided for every opinion provided that considers the Veteran's specific circumstances.

Nathaniel Doan

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board N. M. Younan

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.

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