Citation Nr: 1800180 Decision Date: 01/03/18 Archive Date: 01/19/18 DOCKET NO. 08-33 198 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for hemorrhoids. 2. Entitlement to service connection for colon polyps, claimed as diverticulitis. 3. Entitlement to service connection for gastroesophageal reflux disorder (GERD), to include as secondary to a service-connected disability. 4. Entitlement to service connection for a peptic ulcer or antritis, to include as secondary to a service-connected disability. 5. Entitlement to service connection for a respiratory disability, to include as secondary to a service-connected disability, including service-connected tuberculosis (TB)/treatment for TB. 6. Entitlement to service connection for a bilateral hips disability to include as secondary to a service-connected disability, including TB/treatment for TB. 7. Entitlement to service connection for a heart disorder to include as secondary to TB/treatment for TB. 8. Entitlement to service connection for a left knee disability. 9. Entitlement to service connection for a cervical spine disorder, claimed as a pinched neck nerve. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran served on active duty from April 1979 to July 1990 with service in the Army Reserve. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The Veteran and his friend testified before a Decision Review Officer (DRO) at the RO in Indianapolis, Indiana in May 2009. The Veteran also testified at a Travel Board hearing before the undersigned at the RO in June 2012. Transcripts of both hearings are in the record. The issues of entitlement to service connection for hypertension, alcohol abuse, fatty deposits of the liver, high cholesterol, and joint pain, other than of the left knee and bilateral hips were adjudicated in a September 2013 Board decision. The issues of entitlement to service connection for chest pain/costochondritis, entitlement to an initial compensable evaluation for residuals of tuberculosis (TB), and entitlement to an initial compensable rating for residuals of a left varicectomy were adjudicated in a February 2015 Board Decision. Both decisions remanded the remaining issues listed on the first page of this decision. These matters were most recently remanded in October 2016 for further development. The claims of entitlement to service connection for asthma, hemorrhoids, and colon polyps/diverticulitis are ready for adjudication. In August 2017, the Veteran signed an expedited waiver of the 30 day waiting period and Agency of Original Jurisdiction (AOJ) consideration of additional evidence of new evidence. The issues of entitlement to service connection for a left knee disorder and cervical spine disorder are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's hemorrhoids, colon polyps (claimed as diverticulitis) and respiratory disability were not manifest during service or for many years thereafter, and the competent and credible evidence fails to establish an etiological relationship between the Veteran's claimed disabilities and his active service or a service-connected disability. CONCLUSION OF LAW Hemorrhoids, colon polyps, and a respiratory disability were not incurred in or aggravated by service, and may not be presumed related to a service-connected disability. 38 U.S.C. §§ 1110 , 1111, 1131, 1132, 5103(a), 5103A (West 2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist In this case, there is no indication in this record of a failure to notify. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). Pursuant to the duty to assist, VA must obtain "records of relevant medical treatment or examination" at VA facilities. 38 U.S.C.A. § 5103A(c)(2). All records pertaining to the conditions at issue are presumptively relevant. See Moore v. Shinseki, 555 F.3d 1369, 1374 (Fed. Cir. 2009); Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010). In addition, where the Veteran "sufficiently identifies" other VA medical records that he or she desires to be obtained, VA must also seek those records even if they do not appear potentially relevant based upon the available information. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (citing 38 C.F.R. § 3.159(c)(3)). With regard to the claims for service connection for low back and right hand disorders, the record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to these claims. Pertinent medical evidence associated with the claims files consists of the available service treatment records (STRs), VA treatment records, and private treatment records. The Veteran was afforded relevant VA examinations with regard to his hemorrhoids, colon polyps and diverticulitis in November 2013 (pursuant to a September 2013 remand) and an addendum was obtained in May 2015 (pursuant to a February 2015 remand). Pursuant to an October 2016 remand, a May 2017 VA examination was obtained which cured the deficiencies found in the prior VA examination and opinion. With regard to the respiratory disorders claim, a VA examination was obtained in August 2009. A VA examination was obtained in November 2013 (pursuant to a September 2013 remand) and an addendum was obtained in May 2015 (pursuant to a February 2015 remand). Pursuant to the Board's October 2016 remand, a May 2017 VA examination and opinion were obtained which cured the deficiencies found in the prior VA examiner's opinion. The Board finds that the May 2017 VA examination reports and opinions show that the examiner considered the evidence of record and the reported history of the Veteran, conducted thorough VA examinations, noting all findings necessary for proper adjudication of the matters, and explained the rationale for the opinion offered. Hence, the Board finds that the May 2017 VA examinations and medical opinions obtained in this case are adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C. § 5103A and 38 C.F.R. § 3.159 and that there has been substantial compliance with its remands. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In addition to the regulations cited above, service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (2017). Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Finally, 38 U.S.C.A. § 1154 (a) requires that VA give 'due consideration' to 'all pertinent medical and lay evidence' in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Specifically, '[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.' Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Hemorrhoids, colon polyps, diverticulitis The Veteran contends that during service he experienced constipation caused by "lack of roughage that came with required military diet of C-Rations and MREs which could reduce and narrow the bowel lumen and lead to constipation and lead to hemorrhoids." See, May 2009 statement. The STRs are void of any findings, complaints, symptoms, or diagnosis related to hemorrhoids, colon polyps, diverticulitis, or constipation. Post service, private treatment records include a January 2006 CT of the abdomen and pelvis which indicates abdominal pain and constipation. The impression was mild inflammatory change involving the distal descending colon and findings likely related to mild diverticulitis and the remainder of the examination was within normal limits. A June 2006 report indicates a history of polyps, left lower quadrant pain, and a history of diverticulitis requiring antibiotic therapy. His symptoms had been present for the last year. The impression included a history of polyps, left lower quadrant pain, and diverticulitis. Private treatment records include a July 2012 colonoscopy and the colon was normal with internal hemorrhoids. In September 2012, the Veteran testified that his colon polyps were removed. He also testified that he had hemorrhoids due to consuming MREs and stated that he did not seek treatment during service due to embarrassment. Pursuant to a September 2013 remand, on November 2013 VA rectus and anus conditions Disability Benefits Questionnaire (DBQ) examination, the examiner noted a diagnosis of hemorrhoids in 2012 and internal neoplasm in June 2013. The Veteran stated that he developed constipation associated with eating MREs. He reported painful bowel movements with blood in his stool. An in-service examination dated in March 2002 noted a normal rectal examination. He reported no further constipation. A single mild internal hemorrhoid was noted in a routine colonoscopy in 2012. In the medical history section of the examination report, it was noted that the Veteran was diagnosed with diverticulosis during a June 2006 colonoscopy. A July 2012 colonoscopy indicated no diverticulosis was noted. The Veteran reported that he was treated for diverticulitis at a private hospital and had a history of a benign colonic polyp. The examiner opined that the claimed colon polyps, diverticulitis, and hemorrhoids clearly and unmistakably existed prior to service and were clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness based on the rationale that there is no evidence or association between the use of NSAIDs and hemorrhoids, colonic polyps, or diverticulosis. The examiner also opined that the Veteran developed an episode of constipation during a period of time he was eating MREs. This is not an unusual report. The Veteran reported rectal pain and bleeding. There was no evidence of hemorrhoids at the time of a physical examination in March 2002. A review of his medical records did not reveal any further complaints or a return of symptoms. He was found to have asymptomatic non-bleeding internal hemorrhoid at the time of a colonoscopy in 2012. It should be noted that the upper 2/3rd of the anal canal has no pain receptors. If he had a painful bleeding due to a hemorrhoid it would have been from below that area. However, he did not have any visible signs of a hemorrhoid prolapse or by history and there was no evidence of an external hemorrhoid at the time of his in-service examination in 2002. In a February 2015 remand, the Board noted that on November 2013 VA examination, with regard to service connection for hemorrhoids and colon polyps (claimed as diverticulitis), the examiner opined that the claimed conditions clearly and unmistakably existed prior to military and were not clearly and unmistakably aggravated beyond the natural progression of the diseases by military service. However, the Veteran's entrance examination did not note any of these disabilities as present when he entered service nor did the examiner provide a rationale for that conclusion. Thus, an addendum was requested from a VA examiner other than the examiner who conducted the November 2013 examination. However, a May 2015 addendum was provided by the November 2013 VA examiner in which she opined that the claimed colon polyps and diverticulitis were not incurred in or caused by service based in part on the rationale that colon polyps and diverticulitis are two separate and distinct diagnoses. The examiner explained that the pertinent STRs and medical records were reviewed and that with regard to hemorrhoids his rectal examination was reported normal on separation examination in May 2002. The examiner noted that there are no STRs indicating the presence of internal or external hemorrhoids and no medical records indicating hemorrhoids within a year of separation from service. The examiner rendered the opinion after consideration of the Veteran's contention that he developed colon issues due to the diet and bathroom irregularities during service. With regard to colonic polyps, the examiner noted that civilian medical records indicated colonic polyps at the time of a colonoscopy which was required as part of his pre-liver transplant work. The polyps were found incidentally at the colonoscopy in 2012. There was no evidence of pre-existing colonic polyps. With regard to diverticulitis there was no report or clinical records of a diagnosis of treatment for colonic diverticulitis. The examiner explained that one had to have colonic diverticulosis in order to develop colonic diverticulitis. The Veteran's colonoscopy did not reveal colonic diverticulosis, the necessary prerequisite for diverticulitis. The examiner stated that is no evidence that he was ever diagnosed with diverticulitis. On October 2016 remand, the Board noted that contrary to prior remand directives, the May 2015 VA medical opinion was provided by the November 2013 VA examiner. In discussing gastrointestinal diagnoses such as colon polyps and hemorrhoids, the examiner noted no findings in service as a basis for the negative opinion and appeared to rely upon the lack of contemporaneous documentation as a basis for the negative opinion. Pursuant to the Board's October 2016 remand, on March 2017 VA intestinal conditions DBQ examination, the Veteran presented with a history of diverticulitis since 1999 and a 2006 diagnosis of diverticulitis. The Veteran presented with a long history of bowel complaints. In 1989 he was evaluated for abdominal pain, but a 1999 barium enema was normal. In 1999 he was evaluated for diarrhea and diagnosed as having a spastic colon. He has been found to have diverticulosis and at least a couple of episodes of diverticulitis since discharge from active duty. In 2006, he was seen for recurrent LLQ pain and was noted to have received treatment for diverticulitis. A colonoscopy was negative for polyps. Mild sigmoid diverticulosis was noted without clinical diverticulitis. The examiner diagnosed diverticulitis since 2006. With regard to colon polyps, the VA examiner opined that there is no evidence that the Veteran had colon polyps. Moreover, most colon polyps are harmless small growths that cause no symptoms and typically occur in patients over the age of 50. The examiner explained that it is a benign growth that is not associated with the Veteran's service connected conditions. Colon polyps can cause bleeding and can have malignant degeneration. For this reason they are usually removed but not because of the condition of having a polyp. There was no evidence of any polyp condition with associated bleeding or malignant degeneration. He was reported to have a finding of benign polyps at the time of a routine screening colonoscopy done when he was placed on a list for a liver transplant, but there was no other record of colonic polyps and even if he had a colon polyp condition, the examiner indicated that there was no associated disability. The examiner stated that a review of his records shows in 10-26-99 he had diarrhea for 3 month with the diagnosis of spastic colitis. A GI note from 6-12-06 states the veteran has a history of diverticulitis requiring antibiotic therapy A CT of the abdomen 7-30-08 reveals evidence of diverticulosis without diverticulitis, as well as an abnormal liver and a large amount of ascites. I do not find any other evidence for the condition of diverticulitis. With regard to hemorrhoids, the VA examiner stated that the Veteran developed an episode of constipation during a period of time he was eating MRE's which is not an unusual report. The Veteran reported rectal pain and bleeding. However, there was no evidence of hemorrhoids on May 2002 separation examination. A review of his medical records did not reveal any further complaints or a return of symptoms. A 2003 colonoscopy was normal with the exception of one small polyp. A 2006 colonoscopy was normal with the exception of diverticulosis. He was found to have an asymptomatic non-bleeding internal hemorrhoid during a 2012 colonoscopy. The examiner indicated that the Veteran had not had any surgical treatment for hemorrhoids and opined that there is no evidence of hemorrhoids related to his military service and no evidence of disability due to hemorrhoids. Here, there is no competent medical evidence to that the Veteran has hemorrhoids, colon polyps, or diverticulitis that are related to his service. Respiratory disorder In a May 2009 statement in support of claim, the Veteran claimed that his asthma was caused by tuberculosis. He also claimed that his respiratory problems throughout his career could be attributed to occupational exposures to diesel fumes in motor pools. Inhalation of trail dust caused by track vehicles, no respiratory protection or masks were allowed. The STRs include September and October 1989 clinical note which indicate an assessment of chronic bronchitis. A December 1989 clinical note indicates a diagnosis of questionable URI. A January 1990 chest x-ray was normal. A June 1990 ETS report of medical history indicates a complaint of tuberculosis (TB) for TB treatment. On August 2009 VA respiratory examination, the Veteran presented with a history of asthma since 1983/1984 and stated that he had it during service. The examiner diagnosed an obstructive respiratory disorder. The examiner opined that asthma was not caused by or result of military service based on the rationale that no evidence of asthma was found in the STRs. The examiner also opined that TB is not known to cause asthma and noted that the 1999 PFTs were not indicative of asthma. In September 2012, the Veteran testified that he had respiratory symptoms related to changes in the weather rather than the seasons. Pursuant to a September 2013 remand, in a November 2013 VA respiratory conditions DBQ examination indicates a history of tuberculosis, AFB positive. No pulmonary lesions since 1990. The medical history indicates a negative AFB smear in September 1989. He was diagnosed with bronchitis which was resolved in October 1989 and treated with antibiotic. He had a URI in November 1989, but a December 1989 chest X-ray was interpreted as negative as were chest films of January and May 1990. In January 1990, he was diagnosed with TB after his sputum cultures were positive TB. He was treated with triple therapy none of which were steroids. A 2011 chest X-ray was negative and he denied any respiratory problems. With regard to whether the Veteran's TB residuals caused or aggravated another respiratory condition, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness based on the rationale that the Veteran reported no residual symptoms of TB and that the chest films since 1993 did not indicate any abnormality or residuals of TB. The examiner also opined that the claimed condition, clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The rationale was that the Veteran had no chest film abnormalities to support a respiratory condition. He was asymptomatic at the time of his exam and his PFTs did not support a diagnosis of asthma. While the pulmonologist noted a minimally restrictive ventilatory defect on PFTs his chest x-ray and symptoms did not suggest a pulmonary process such as fibrosis or allergic reaction due to inhaled particles. In a February 2015 remand, the Board requested a VA medical addendum from an examiner other than the examiner who performed the November 2013 VA examination. The Board noted that on November 2013 VA examination, with regard to service connection for a respiratory disorder (other than TB), the examiner opined that the claimed conditions clearly and unmistakably existed prior to military and were not clearly and unmistakably aggravated beyond the natural progression of the diseases by military service. However, the Veteran's entrance examination did not note any of these disabilities as present when he entered service nor did the examiner provide a rationale for that conclusion. Further, there did not appear to be a basis in the STRs. Thus, an addendum was requested from a VA examiner other than the examiner who conducted the November 2013 examination. However, in May 2015 the November 2013 VA examiner provided an addendum in which the examiner opined that the Veteran's respiratory disorder was not incurred or related to his service. The rationale was that the Veteran was noted to have minimal restrictive ventilator defect without defect without a response bronchodilators at the time of the November 2013 PFTs. This was minimal. The examiner noted that he was a former smoker and ceased smoking in 2008. The most recent testing did not support a diagnosis of asthma. It was noted that he reported exposure to motor pool fumes and dues and asbestos as well as years of fumes and contaminates contained in cigarette smoke as well. There was no indication that he had asbestosis. He had none of the classic findings expected on chest films and had no evidence of such findings. In an October 2016 remand, the Board noted that the May 2015 addendum was provided by the same examiner who performed the November 2013 VA examiner and the addendum opinion was either incomplete or did not sufficiently discuss all the aspects or evidence regarding the Veteran's claim. In this regard, the Board noted the May 2015 examiner discussed whether exposure to asbestos caused a current respiratory disability, but did not discuss the Veteran's reports of other environmental exposures in service that he believes played a role in causing his respiratory disability. The examiner also did not discuss the Veteran's assertions that he has a respiratory disability secondarily caused by the Veteran's service connected disabilities. In addition, the examiner determined the Veteran did not have asthma, but did not discuss the medical evidence in the record that the Veteran had been diagnosed with asthma. In any event, the examiner acknowledged the Veteran had a restrictive ventilatory defect, but did not determine if the restrictive ventilatory defect was connected to his service. Pursuant to the Board's October 2016 remand, in March 2017 the Veteran was afforded a VA examination by an examiner other than the November 2013 VA examiner who diagnosed asthma since 2015 which the examiner opined was less likely than not related to his service. The rationale was that review of the Veteran's STRs does not show a diagnosis of asthma or other respiratory condition. The examiner noted that there was no definitive diagnosis of asthma until 2015 and considered the March 2015 private pulmonary specialist's report that he was noted to have cough, wheezing and sensitivity to various agents required inhaled steroids. It was noted that his asthma "may have started when he was in the barracks in Germany where there was a lot of mold." However there is no definitive diagnosis of asthma until 2015. PFTs done in 2005 show a restrictive defect more consistent with restriction of his breathing capacity that could be due to his cirrhosis and ascites. I cannot find a nexus of symptoms, diagnosis and ongoing care for the condition of asthma related to his military service with possible mold exposure. As for allergies, there is the 1999 statement that he had allergies since he was a teenager. Mold allergies can trigger asthma attacks. However, I do not find record of the diagnosis of asthma in active duty that would have been triggered by mold exposure. The examiner opined that it is less likely than not that the Veteran's current respiratory condition is related to his military service. The examiner also opined that the Veteran's asthma is less likely than not proximately due to or the result of the Veteran's service-connected condition. The rationale was that it is less likely than not that the Veteran's current condition of asthma is related to medications taken for his service connected conditions. During his evaluation in 2015 he was determined to have asthma with chronic cough and wheezing with sensitivity to various agents, but no medications were listed or treatment for other medical conditions noted in a causative manner. The examiner did not find any record of ongoing treatment for a medical condition related to his symptoms of wheezing. The examiner also opined that it is not at least as likely as not that the asthma is aggravated beyond its natural progression by any service-connected disability. The rationale is that he had just recently been diagnosed with asthma and his symptoms are well controlled on his current medical regimen. There is no evidence of aggravation. He has not been hospitalized for the condition, current PFTs show mild obstructive defect. While he does have to have periodic treatment with steroids due to allergic phenomena, with his long standing history of allergies even prior to military service it is not likely that any other condition has aggravated his condition beyond its natural progression. Asthma is characterized by a reversible obstructive defect due to reactive airways. With regard to the Veteran's testimony and evidence of exposure in service to mild dust and diesel fuels, the examiner stated that she reviewed the information. He discussed exposure to asbestos 1985-90 as well as dust and particles and exposure to mold and fumes. He stated that he suffered greatly from current respiratory symptoms related to this exposure. However his May 2002 separation examination is negative for asthma or respiratory problems. The examiner explained that although the Veteran detailed exposure in association with his military service, she did not find a confirmed diagnosis of asbestosis, nor did she find testing that demonstrated a severe mold allergies. The Veteran is noted to have allergies that predated military service with long standing sinus issues. She did not find a diagnosis of asthma during active duty. Exposure to mold or other inhaled allergens could aggravate asthma, but the examiner did not find it as an active diagnosis until 2006 and later confirmed by a pulmonary specialist in 2015. She could not relate her current asthma to military service. The record includes a March 2015 medical opinion and June 2017 DBQ examination and medical opinion from Dr. K.D. In March 2015, he indicated a diagnosis of asthma which the Veteran stated began when in his barracks in Germany where there was a lot of mold. Dr. K.D. opined that this "may have led" to his current asthma symptoms. In June 2017, he opined that his asthma is "more likely as not related to military service," but did not provide any rationale for either opinion. In this case, the Board finds that the March 2017 VA medical examination and opinion provides highly probative and overwhelming evidence against this claim. In March 2017, a VA examiner reviewed the claims file, considered the Veteran's documented and reported history, and performed a thorough evaluation. The examiner diagnosed asthma which she opined was not related to service or any service-connected disability supported by a conclusion with a sufficient rationale. Therefore, the VA medical examinations and opinions provide probative evidence against the Veteran's claim of high probative weight. See Nieves -Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board has considered the private March 2015 and June 2017 medical opinions of Dr. K.D. who opined that in-service mold exposure "may have led" to his asthma symptoms and that his asthma is "more likely as not related to military service." However, neither opinion is shown to have been based on a review of the Veteran's case as a whole. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). It is true that a review of the claims failure or lack thereof does not control the probative value of a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). However, these reports warrant less probative weight as none of them, unlike the March 2017 VA examination report, for example, is based on a current respiratory evaluation of the Veteran and complete review of the entire claims file. Id. Moreover, the March 2015 opinion that in-service mold exposure "may have led" to the Veteran's asthma is, at best, a highly speculative opinion. It is well-established that a speculative opinion cannot be used to establish a claim for benefits. See Stegman v. Derwinski, 3 Vet. App. 228 (1992) (held that did little more than suggest a possibility that his illnesses might have been caused by service radiation exposure was insufficient to establish service connection). The Board finds that the claim must be denied. There is no competent medical evidence to show that the Veteran has any respiratory disorder, including asthma, that is related to his service or to his service-connected TB. The Board has taken the contention that the Veteran's claimed respiratory disorder, colon polyps, hemorrhoids, and diverticulitis were caused by his service, or are related to service-connected disability, with great care (this was the basis of multiple Board remands in order to address these medical questions). The Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's service and his claimed disabilities. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issues in this case, the etiology of hemorrhoids, colon polyps, or diverticulitis, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In light of the above discussion, the Board concludes that the preponderance of the evidence is against the claims for service connection and there is no doubt to be otherwise resolved. As such, the claims are denied. ORDER Service connection for hemorrhoids, is denied. Service connection for colon polyps, claimed as diverticulitis, is denied. Service connection for a respiratory disability, is denied. REMAND Unfortunately, a remand is required in this case. Although the Board sincerely regrets the delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. With regard to the claims for service connection for GERD, a peptic ulcer/antritis, bilateral hips, and heart disorder, on March 2017 the VA examiner indicated that these disabilities were related to alcohol consumption which the Veteran has related to a pending PTSD claim. With regard to the Veteran's GERD and peptic ulcer, the VA examiner opined that "excess alcohol ingestion which is both an irritant to the stomach as well as a contributor to lower esophageal sphincter dysfunction with reflux." With regard to his bilateral hip disorder, the examiner opined that it is known that he has a history of alcohol abuse, alcoholic liver diseases, cirrhosis which has a strong association with avascular necrosis of the hips. With regard to his heart disorder, the examiner opined that he was known to have an enlarged heart likely due to his known alcoholic liver disease. The Veteran has contended that his alcohol abuse is related to his psychiatric disorder, namely, posttraumatic stress disorder (PTSD). In an October 2016 remand, the Board referred the Veteran's claim for service connection for an acquired psychiatric disorder to the AOJ. In August 2017, it was referred to the Indianapolis Regional Office processing. As the Veteran's claims for service connection for GERD, a peptic ulcer/antritis, bilateral hips, and heart disorder indirectly contemplate the referred claim for an acquired psychiatric disorder, the Board finds that the issues of entitlement to service connection for GERD, a peptic ulcer/antritis, bilateral hips, and heart disorder are inextricably intertwined with the referred issue of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. Therefore, the Board may not properly review the Veteran's claim for entitlement to service connection for GERD, a peptic ulcer/antritis, bilateral hips, and heart disorder until the AOJ develops and adjudicates the referred claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered); Holland v. Brown, 6 Vet. App. 443, 445-46 (1994). With regard to the claims for service connection for neck and left knee disabilities, on March 2017 VA DBQ examinations, the examiner noted that the original claims for service connection was for avascular necrosis of the left knee and neck. On examination, the examiner found no evidence of avascular necrosis of the left knee or neck. Instead, the examiner diagnosed an "impaction fracture with MCL strain" and degenerative disc disease of the cervical spine, but failed to render any opinion as to whether the neck and left knee disabilities are related to the Veteran's service because he did not have the claimed disabilities. As it remains unclear whether the Veteran's left knee and neck disabilities are related to his service, a VA medical opinion must be obtained. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007), Stegall v. West, 11 Vet. App. 268 (1998). Accordingly, the case is REMANDED for the following actions: 1. The AOJ should undertake all appropriate development and then adjudicate the referred claims. 2. Provide the claims file to an appropriate VA examiner, other than the November 2013 and March 2017 VA examiners, who should determine whether a new VA examination is warranted in order to provide a medical opinion regarding the nature and etiology of the Veteran's neck and left knee disabilities. The claims file, including a copy of this remand, must be made available to the examiner for review who should indicate that the claims file was reviewed. The examiner must provide the following opinion: Is it at least as likely as not (50 percent or more probability) that any left knee and neck disabilities had their onset in or are etiologically-related to the Veteran's active duty service. The examiner should specifically comment on the Veteran's lay statements concerning the onset and progression of his left knee and neck disabilities. The report of examination should include the complete rationale for all opinions expressed. If an opinion cannot be rendered without resorting to speculation, the physician should explain why it would be speculative to respond. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate review, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ KELLI A. KORDICH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs