MAJOR DEPRESSIVE DISORDER

A. ISHIZAWAR · 2026 · Case ID: A26039414

MIXED

Summary

The veteran served from August 1973 to August 1976, including service in Korea. The veteran appealed the denial of service connection for an acquired psychiatric disorder, specifically persistent depressive disorder and alcohol use disorder, and the grant of service connection for pseudofolliculitis barbae. The Board denied the psychiatric disorder claim, finding the veteran's lay statements regarding onset and chronicity inconsistent and contradicted by earlier VA treatment records that denied PTSD and traumatic experiences. The Board found the private medical opinion from Dr. Q.A. lacked probative weight due to its failure to address the veteran's contradictory statements and reliance on an inaccurate factual premise regarding a TERA memorandum. The Board found the weight of the evidence against a nexus for the psychiatric disorder. For pseudofolliculitis barbae, the Board found the VA examiner's opinion inadequate as it focused on herbicide exposure and lacked adequate consideration of the veteran's lay statements and the chronicity of symptoms. However, the Board found the private medical opinion from Dr. R.P. more probative, noting the veteran's consistent history of skin irritation since service, the known pathophysiology of the condition, and the occupational context. The Board granted service connection for pseudofolliculitis barbae. The claims for diabetes mellitus type II, congestive heart failure, obstructive sleep apnea, glaucoma (secondary to diabetes), and varicose veins were remanded for additional VA medical opinions due to inadequacies in the prior opinions and the need to address the veteran's lay statements and claimed toxic exposures.

Rationale

Inconsistent lay statements regarding symptom onset; Contradicted by earlier VA treatment records; Private medical opinion lacked probative weight

Special Benefit

NO SPECIAL BENEFIT

Docket No.

230908-375710

Full Decision Text

Citation Nr: A26039414
Decision Date: 04/28/26 Archive Date: 04/28/26

DOCKET NO. 230908-375710
DATE: April 28, 2026

ORDER

Service connection for an acquired psychiatric disorder, to include persistent depressive disorder and alcohol use disorder, is denied.

Service connection for pseudofolliculitis barbae is granted.

REMANDED

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

Entitlement to service connection for congestive heart failure is remanded.

Entitlement to service connection for obstructive sleep apnea is remanded.

Entitlement to service connection for glaucoma, to include as secondary to diabetes mellitus type II, is remanded.

Entitlement to service connection for a varicose veins disability is remanded.

FINDINGS OF FACT

1. The persuasive evidence of record is against finding that the Veteran's current acquired psychiatric disorder, to include depressive disorder and alcohol use disorder, had an onset during his period of service or is a result of his period of service.

2. Resolving all reasonable doubt in the Veteran's favor, his pseudofolliculitis barbae is etiologically related to his active military service.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include persistent depressive disorder and alcohol use disorder, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for entitlement to service connection for pseudofolliculitis barbae have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from August 1973 to August 1976.

The rating decision on appeal was issued in August 2023 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the September 2023 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on July 15, 2025.

Therefore, the Board may only consider the evidence of record at the time of the August 2023 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claims of service connection for diabetes mellitus type II, congestive heart failure, obstructive sleep apnea, glaucoma, and a varicose veins disability, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (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. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

When the evidence is in approximate balance in the Veteran's favor or nearly equal regarding any issue
disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (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. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

When the evidence is in approximate balance in the Veteran's favor or nearly equal 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; see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

1. Entitlement to an acquired psychiatric disorder, to include persistent depressive disorder and alcohol use disorder

The Veteran contends that entitlement to service connection for an acquired psychiatric disorder is warranted. As an initial matter, the Board notes that the issue on appeal has been recharacterized from one specific to posttraumatic stress disorder (PTSD) to include any potentially relevant acquired psychiatric disability claims raised in the record, to include persistent depressive disorder and alcohol use disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009).

In this case, medical treatment records indicate that the Veteran has a diagnosed acquired psychiatric disorder. Specifically, the Veteran has a diagnosis of persistent depressive disorder and alcohol use disorder based on private treatment records. A current disability has therefore been demonstrated. Additionally, the Veteran has stated that he experienced psychiatric disorder symptoms during service. Specifically, the Veteran has stated that he experienced symptoms of isolation and depression during service. Additionally, the Veteran reported while stationed at the demilitarized zone (DMZ) in Korea, he heard firing in the distance and feared for his safety. Accordingly, an in-service injury has been shown.

As the record contains evidence of a current disability, and evidence of an in-service injury or disease, what remains to be established is whether there is a nexus between the Veteran's psychiatric disorder and his in-service disease or injury.

VA treatment records show that on August 10, 2022, the Veteran presented to the Geriatric Evaluation and Management (GEM) clinic for enrollment. His past medical history was noted to include diabetes mellitus, type II, congestive heart failure, gout, and osteoarthritis; a past mental health history was not reported. During the initial social work comprehensive assessment, the Veteran reported no concerns about his cognition although he had "some depression" sometimes. Upon administration of the depression screening tool (PHQ-2), the Veteran responded that "several days" he had little or no pleasure during this week. This was attributed to his ongoing issues with his knee for which he had surgery in 2015. He denied feeling down, depressed, or hopeless.

Also on August 10, 2022, the Veteran underwent a geriatric consultation. The Veteran reported being forgetful at times and interested in a psychological evaluation. On August 17, 2022, a clinical psychologist spoke with the Veteran who acknowledged some memory troubles but did not think it was "that severe." Due to the memory concerns, an appointment was made for a geropsychology intake later that month.

On August 25, 2022, the Veteran was seen for his geropsychology intake appointment. The Veteran was asked about his military history; he reported serving during the Vietnam Era and being stationed at Ft. Campbell and Korea. He denied PTSD experiences. His past psychiatric history was also reviewed; it was noted that he had worked with mental health for an alcohol use disorder. He denied a history of traumatic experiences, but endorsed sadness related to "losing brothers" and being depressed at times in the context of losing loved ones. He also answered reported that he had "maybe" contemplated self-harm in the contest of separation from his wife in the past. Presently, he reported having a sluggish mood, especially over the past couple of years during the pandemic. He also reported feeling depressed every now and then primarily when he was unable to engage in regular activity. Following this consultation, the clinical psychologist diagnosed an unspecified neurocognitive disorder (rule out age-related change versus mild neurocognitive disorder). The clinical psychologist further noted that the Veteran acknowledged occasional depressed mood and anhedonia but stated that there was no indication of clinically significant mood or other psychiatric disturbance.

The Veteran had a hearing before the Board in July 2025.
context of losing loved ones. He also answered reported that he had "maybe" contemplated self-harm in the contest of separation from his wife in the past. Presently, he reported having a sluggish mood, especially over the past couple of years during the pandemic. He also reported feeling depressed every now and then primarily when he was unable to engage in regular activity. Following this consultation, the clinical psychologist diagnosed an unspecified neurocognitive disorder (rule out age-related change versus mild neurocognitive disorder). The clinical psychologist further noted that the Veteran acknowledged occasional depressed mood and anhedonia but stated that there was no indication of clinically significant mood or other psychiatric disturbance.

The Veteran had a hearing before the Board in July 2025. The Veteran testified that he was fired on while stationed at the DMZ in Korea. The Veteran further testified feeling "numb" in service, which led to increased drinking. Additionally, the Veteran's spouse testified that his behavior changed. Specifically, she noted that the Veteran was more impatient, he had increased nervousness, and that he would get very anxious, until he would get a drink.

Following the Board hearing, the Veteran submitted a June 2025 private medical opinion from Dr. Q.A., Ph.D., a private psychologist who had been asked by the Veteran's representative to review the file and provide a medical opinion. Following a review of the Veteran's claims file and an interview of the Veteran, the private psychologist indicated that the Veteran had a diagnosis of persistent depressive disorder and alcohol use disorder in sustained remission. Dr. Q.A. opined that it was at least as likely as not that the Veteran's persistent depressive disorder and alcohol use disorder began during military service. Dr. Q.A. noted that the Veteran reported feeling that "bootcamp was rough" and that he began drinking to excess at his first duty station. Dr. Q.A. noted that this continued to worsen over time. The Veteran reported that while in Korea he was a radar operator near the demilitarized zone, that a lieutenant got killed on the DMZ, and that this left him feeling isolated and depressed. Dr. Q.A. stated that the Veteran appeared to be a "credible and reliable reporter of his experiences and symptoms" and that his reports of military experiences and the stressful time he experienced in Korea were consistent with known experiences and history of Korean deployment at that time. Dr. Q.A. concluded that it was reasonable to believe that the Veteran's anxiety and depression could have begun in service, and that it was as likely as not that his persistent depressive disorder began during military service.

After consideration of the evidence, the Board concludes that the persuasive evidence of record weighs against finding that the Veteran's current acquired psychiatric disorder began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d).

The Board notes with significance that the Veteran's lay statements regarding the onset of his symptoms have been inconsistent and are contradicted by other documents of record. The Veteran testified as part of his claim for compensation that he was fired upon while serving at the DMZ in Korea. Additionally, the Veteran reported being affected by the death of a lieutenant on the DMZ in his private medical assessment. However, in treatment records from August 2022, only a few months prior to the filing of his claim, the Veteran denied PTSD experiences and a history of traumatic experiences. Additionally, while the Veteran endorsed that he "Maybe" contemplated self-harm, he indicated that it was in the context of separation from his wife in the past. Similarly, for present mental health symptoms, the Veteran related experiencing some depression and sluggish mood related to physical disabilities, aging and the loss of loved ones, and current events such as the pandemic. He did not endorse depressive symptoms related to his military service.

The Board finds it reasonable to believe that had the Veteran suffered from mental health symptoms related to his military service, he would have disclosed a history of such when asked directly about it during his August 2022 VA geropsychology intake appointment, particularly as the evaluation was being completed for the purposes of ensuring the Veteran received proper medical care. See Harvey v. Brown, 6 Vet. App. 390, 393-94 (1994) (drawing a credibility distinction between statements made for the purpose of receiving treatment and those made for the purpose of seeking compensation). For these reasons, the Board is unable to find the Veteran's reports of experiencing mental health symptoms related to his military service to be credible. See Gardin v. Shinseki, 613 F.
believe that had the Veteran suffered from mental health symptoms related to his military service, he would have disclosed a history of such when asked directly about it during his August 2022 VA geropsychology intake appointment, particularly as the evaluation was being completed for the purposes of ensuring the Veteran received proper medical care. See Harvey v. Brown, 6 Vet. App. 390, 393-94 (1994) (drawing a credibility distinction between statements made for the purpose of receiving treatment and those made for the purpose of seeking compensation). For these reasons, the Board is unable to find the Veteran's reports of experiencing mental health symptoms related to his military service to be credible. See Gardin v. Shinseki, 613 F.3d 1374, 1379 (Fed. Cir. 2010) (upholding the Board's finding that vague and inconsistent lay statements were not credible because they were in direct contradiction to the more credible, competent, reliable, and clearly documented medical evidence).

The Board acknowledges the private medical opinion from Dr. Q.A., Ph.D., but does not afford it significant probative weight. Dr. Q.A.'s opinion did not adequately address the Veteran's earlier contradictory lay statements denying PTSD experiences and a history of traumatic experiences, as well as his statements attributing past psychological issues to separation from his spouse. For these reasons, the Board finds that the weight of the competent, credible, and probative evidence of record does not establish a nexus between currently diagnosed acquired psychiatric disorder and active service. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinion based on inaccurate factual premise may properly be rejected as non-probative); see also Coburn v. Nicholson, 19 Vet. App. 427, 432-33 (2006) (Board may reject probative value of medical opinion if based on discredited statements made by veteran).

While the Veteran believes he has an acquired psychiatric disorder as a result of his military service, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires medical knowledge. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011).

For the reasons discussed above, the Board finds that the persuasive evidence of record is against the claim for service connection for an acquired psychiatric disorder, and the appeal is denied. In making this determination, the Board has considered the provisions of 38 U.S.C. § 5107(b) regarding benefit of the doubt, but there is not such a state of equipoise of positive and negative evidence to otherwise grant the Veteran's claim.

2. Entitlement to service connection for pseudofolliculitis barbae

The Veteran contends that entitlement to service connection for pseudofolliculitis barbae is warranted.

In this case, it has been conceded that the Veteran has a diagnosis of pseudofolliculitis barbae. A current disability has therefore been demonstrated. Additionally, the Veteran has stated that he experienced pseudofolliculitis barbae symptoms during service. Specifically, the Veteran has stated that he would break out in bumps after shaving in the morning during service. Accordingly, an in-service injury has been shown.

As the record contains evidence of a current disability, and evidence of an in-service injury or disease, what remains to be established is whether there is a nexus between the Veteran's pseudofolliculitis barbae and his in-service disease or injury.

The Veteran had a VA examination for his pseudofolliculitis barbae condition in August 2023. The examiner opined that it was less likely than not that the Veteran's pseudofolliculitis barbae was caused by exposure to herbicide agents after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic combined effect of all toxic exposure risk activities of the Veteran. The examiner explained that there was no epidemiologic nor scientific evidence of Agent Orange exposure causing the condition of pseudofolliculitis barbae. The examiner further noted that there had been no identified medical evidence of a causal mechanism to connect Agent Orange to the development of pseudofolliculitis barbae. The examiner also noted that the Veteran's service treatment records were silent for pseudofolliculitis barbae. The examiner observed that pseudofolliculitis barbae was a common condition in new recruits and might have been present in the military,
icide agents after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic combined effect of all toxic exposure risk activities of the Veteran. The examiner explained that there was no epidemiologic nor scientific evidence of Agent Orange exposure causing the condition of pseudofolliculitis barbae. The examiner further noted that there had been no identified medical evidence of a causal mechanism to connect Agent Orange to the development of pseudofolliculitis barbae. The examiner also noted that the Veteran's service treatment records were silent for pseudofolliculitis barbae. The examiner observed that pseudofolliculitis barbae was a common condition in new recruits and might have been present in the military, but the Veteran did not seek care for this and therefore there was no service treatment record documentation for direct service connection.

The Veteran had a hearing before the Board in July 2025. The Veteran testified that he "would just like break out in bumps" from shaving in the morning. The Veteran further testified that he would "try to get shaving cream" and that he "had to add like Vaseline, or whatever [he] could to calm the burning down, because it was burning real bad". Additionally, the Veteran testified that he did not have issues with shaving prior to service and that he had had problems since separation.

Following the Board hearing, the Veteran submitted a June 2025 private medical opinion from Dr. R.P., who had been asked by the Veteran's representative to review the file and provide a medical opinion. Dr. R.P. opined that it was at least as likely as not that the Veteran's current facial skin condition was caused by his military service. Dr. R.P. stated that prior to enlistment, the Veteran did not suffer from any shaving-related skin problems. However, during his military service, the Veteran began experiencing persistent facial irritation, breakouts, and sores specifically related to shaving. Dr. R.P. noted that the Veteran attributed the onset of this condition to the use of military-issued razors and shaving cream, which were harsh and inadequate for his sensitive skin. The Veteran reported that this irritation began in service and had continued since, eventually requiring him to grow a beard after discharge to avoid further skin trauma. Dr. R.P. found the Veteran's account to be consistent with known triggers for pseudofolliculitis barbae, particularly in individuals with sensitive skin subjected to forced shaving under military grooming standards. Dr. R.P. stated that pseudofolliculitis barbae was a common inflammatory skin condition that disproportionately affected military personnel with sensitive skin, especially those of African descent who possessed coarse, curly hair. Dr. R.P. further noted that the condition arose from mechanical trauma associated with shaving, which caused sharp hair shafts to curve back into the skin, triggering an inflammatory response that manifested as papules, pustules, post-inflammatory hyperpigmentation, and even keloidal scarring in severe cases. Dr. R.P. noted that the medical literature confirmed that pseudofolliculitis barbae was among the most frequent dermatologic reasons for military shaving waivers and had long been recognized as a service-aggravated dermatologic disorder. Dr. R.P. stated that although there were no formal service treatment records documenting clinical intervention for the Veteran's facial skin condition during active duty, his lay testimony provided compelling evidence of in-service onset. Dr. R.P. also stated that while this condition might not have been formally diagnosed in service, such underreporting was common in military populations due to stigma, normalization of symptoms, or the perceived lack of available treatment options. Dr. R.P. further stated that the Veteran's longstanding history of facial irritation, beginning during active duty and continuing thereafter, supported chronicity. Dr. R.P. concluded that considering the evidence of symptom onset in service, the established pathophysiology of pseudofolliculitis barbae, and the occupational context in which it developed, it was at least as likely as not that the Veteran's current facial skin condition was caused by his military service.

The Board finds the August 2023 VA medical opinion to be inadequate. Specifically, the Board finds that the August 2023 VA medical opinion focused primarily on whether the Veteran's pseudofolliculitis barbae condition was related to the Veteran's reported in-service exposures. The August 2023 VA examiner's opinion did not adequately address the Veteran's lay statements of record regarding the onset and chronicity of his symptoms. Instead, the August 2023 VA examiner's direct service connection opinion was conclusory and relied on a lack of evidence in the Veteran's service treatment records. Alternatively, the Board finds the June 2025 private medical opinion from Dr. R.P. to carry more probative weight because Dr. R.P. provided a detailed and thorough opinion
VA medical opinion to be inadequate. Specifically, the Board finds that the August 2023 VA medical opinion focused primarily on whether the Veteran's pseudofolliculitis barbae condition was related to the Veteran's reported in-service exposures. The August 2023 VA examiner's opinion did not adequately address the Veteran's lay statements of record regarding the onset and chronicity of his symptoms. Instead, the August 2023 VA examiner's direct service connection opinion was conclusory and relied on a lack of evidence in the Veteran's service treatment records. Alternatively, the Board finds the June 2025 private medical opinion from Dr. R.P. to carry more probative weight because Dr. R.P. provided a detailed and thorough opinion based on the relevant evidence of record and the pertinent medical literature.

The weight of the competent medical evidence of record demonstrates that the Veteran has pseudofolliculitis barbae that was incurred in or caused by their active service. Accordingly, the Board finds that service connection for pseudofolliculitis barbae is warranted, and the claim is granted.

REASONS FOR REMAND

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

2. Entitlement to service connection for congestive heart failure is remanded.

3. Entitlement to service connection for obstructive sleep apnea is remanded.

An individual longitudinal exposure record (ILER) was associated with the record in March 2023. The March 2023 ILER did not contain any results. A toxic exposure risk activity (TERA) memorandum was associated with the record in August 2023. The August 2023 TERA memorandum indicated that the Veteran did not participate in a TERA.

In June 2023, VA medical opinions were obtained regarding the etiology of the Veteran's claimed diabetes mellitus type II and congestive heart failure disabilities. The examiner opined that it was less likely than not that the Veteran's claimed diabetes mellitus type II and congestive heart failure disabilities were caused by the indicated TERA, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERAs of the Veteran. The examiner cited a March 2023 TERA memorandum that showed exposure to an herbicide agent, sand, dust, particulate matter, Fuel, aircraft exhaust, and other mechanical fumes, smoke from oil well fires. The examiner noted that the Veteran had risk factors outside of military service including hypertension and a family history of coronary artery disease and diabetes. The examiner concluded that the Veteran's risk factors outside of military service outweigh the factors identified in the TERA as the cause of his conditions.

A VA medical opinion regarding the Veteran's claimed obstructive sleep apnea disability was also obtained in June 2023. The examiner opined that the claimed condition was less likely than not caused by the indicated toxic exposure risk activities, after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran. The examiner cited a March 2023 TERA memorandum. The examiner stated that there is no pathology to warrant a diagnosis or condition that can be related to the claimed toxic exposure.

Following the Board hearing, the Veteran submitted a June 2025 private medical opinion from Dr. R.P., who had been asked by the Veteran's representative to review the file and provide medical opinions on the Veteran's claimed disabilities. Dr. R.P. provided positive nexus opinions for the Veteran's claimed diabetes mellitus type II, congestive heart failure disabilities, and obstructive sleep apnea disabilities. In the medical opinions, Dr. R.P. stated that the Veteran was exposed to multiple toxic substances, including herbicidal agents (such as TCDD/Agent Orange), diesel exhaust, fuel vapors, aircraft emissions, and particulate matter, as documented in his March 15, 2023, TERA memorandum.

The Board finds the June 2023 VA medical opinions and June 2025 private medical opinions to be insufficient. Specifically, the June 2023 VA medical opinions and June 2025 private medical opinions cited a March 2023 TERA memorandum, which does not appear to be in the record. The only TERA memorandum in the record is from August 2023, which found that the Veteran did not participate in a TERA. Accordingly, the Board must find these opinions to be inadequate, as they are based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (finding a medical examination based on an inaccurate factual premise inadequate for rating purposes).

However, the Board notes that the absence of exposure verification in the March 2023 ILER and August 2023 TERA memorandum does not mean that
June 2025 private medical opinions cited a March 2023 TERA memorandum, which does not appear to be in the record. The only TERA memorandum in the record is from August 2023, which found that the Veteran did not participate in a TERA. Accordingly, the Board must find these opinions to be inadequate, as they are based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (finding a medical examination based on an inaccurate factual premise inadequate for rating purposes).

However, the Board notes that the absence of exposure verification in the March 2023 ILER and August 2023 TERA memorandum does not mean that exposure-related evidence does not exist. Once VA undertakes the effort to provide an examination or medical opinion when developing a service connection claim, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide an examination or obtain an opinion, it must ensure that the examination or opinion is adequate).

Accordingly, remand is appropriate to correct a pre-decisional duty to assist error by obtaining an additional VA medical opinion regarding the etiology of the Veteran's claimed diabetes mellitus type II, congestive heart failure disabilities, and obstructive sleep apnea disabilities.

4. Entitlement to service connection for glaucoma, to include as secondary to diabetes mellitus type II, is remanded.

5. Entitlement to service connection for a varicose veins disability, to include as secondary to diabetes mellitus type II, is remanded.

The Veteran has contended that his claimed glaucoma and varicose veins disabilities are secondary to his diabetes mellitus. Accordingly, a decision on the issue of entitlement to service connection for diabetes mellitus could significantly impact a decision on the Veteran's claims for service connection for glaucoma and varicose veins disabilities. Therefore, the Board finds that the Veteran's claims for service connection for glaucoma and varicose veins disabilities are inextricably intertwined with his appeal regarding entitlement to service connection for diabetes mellitus type II and a remand for the claims for service connection for glaucoma and varicose veins disabilities is necessary. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991).

The matters are REMANDED for the following actions:

1. Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran's current diabetes mellitus type II condition is related to his military service. The record must be made available to and reviewed by the VA examiner.

Following a review of the entire record, the examiner should address the following:

Is it at least as likely as not that the Veteran's diabetes mellitus condition had its onset in, or is otherwise related to his period of active service, to include as a result of the Veteran's claimed toxic risk exposure activity (TERA) while serving in Korea?

In answering the above, the Veteran should address the Veteran's lay statements of record regarding the onset and chronicity of his symptoms. Additionally, the examiner should address the Veteran's lay statements of record regarding his claimed exposure to diesel exhaust fumes and other TERAs while serving in Korea.

The examiner should note that the lack of a diagnosed disability in service cannot serve as the sole basis for a negative finding. Lay contentions must be considered and weighed in making the determination as to whether a nexus exists. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the likelihood is at least approximately balanced or nearly equal, if not higher.

2. Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran's current congestive heart failure condition is related to his military service. The record must be made available to and reviewed by the VA examiner.

Following a review of the entire record, the examiner should address the following:

Is it at least as likely as not that the Veteran's congestive heart failure condition had its onset in, or is otherwise related to his period of active service, to include as a result of the Veteran's claimed toxic risk exposure activity (TERA) while serving in Korea?

The examiner should note that the lack of a diagnosed disability in service cannot
and reviewed by the VA examiner.

Following a review of the entire record, the examiner should address the following:

3. Obtain an addendum medical opinion from a qualified VA medical professional to determine whether the Veteran's current obstructive sleep apnea condition is related to his military service. The record must be made available to and reviewed by the VA examiner.

Following a review of the entire record, the examiner should address the following:

Is it at least as likely as not that the Veteran's obstructive sleep apnea condition had its onset in, or is otherwise related to his period of active service, to include as a result of the Veteran's claimed toxic risk exposure activity (TERA) while serving in Korea?

A. ISHIZAWAR

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board David M. Sebstead

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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