Citation Nr: 18148343 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 15-41 962 DATE: November 7, 2018 ORDER Entitlement to service connection for tinnitus is granted. Entitlement to service connection for a bilateral hearing disorder is granted. Entitlement to service connection for an allergy disorder is denied. Entitlement to service connection for a heart disorder is denied. Entitlement to service connection for an acquired psychiatric disorder and/or a neurocognitive disorder, to include posttraumatic stress disorder (PTSD) and an unspecified neurocognitive disorder is denied. Entitlement to service connection for a sleep disorder is denied. Entitlement to service connection for memory loss is denied. REMANDED Entitlement to service connection for a bilateral hip disorder is remanded. Entitlement to service connection for bilateral knee disorder is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record reflects that the Veteran’s tinnitus is related to his period of active service. 2. The preponderance of the evidence of record reflects that the Veteran’s bilateral hearing loss is related to his period of active service. 3. The preponderance of the evidence of record does not reflect that the Veteran’s allergy disorder is related to his period of active service or any incidents therein. 4. The preponderance of the evidence of record does not reflect that the Veteran’s heart disorder is related to his period of active service or any incidents therein. 5. The preponderance of the evidence of record does not reflect that the Veteran’s acquired psychiatric disorder and/or a neurocognitive disorder is related to his period of active service or any incidents therein. 6. The preponderance of the evidence of record does not reflect that the Veteran’s sleep disorder is related to his period of active service or any incidents therein. 7. The preponderance of the evidence of record does not reflect that the Veteran’s memory loss disorder is related to his period of active service or any incidents therein. CONCLUSIONS OF LAW 1. The Veteran’s tinnitus was incurred in service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. The Veteran’s bilateral hearing loss was incurred in service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.07, 3.09, 3.385 (2017). 3. The Veteran’s allergy disorder was not incurred in service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The Veteran’s heart disorder was not incurred in service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The Veteran’s acquired psychiatric disorder and/or a neurocognitive disorder was not incurred in service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 6. The Veteran’s sleep disorder was not incurred in service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 7. The Veteran’s memory disorder was not incurred in service. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1953 to February 1955. These matters come before the Board of Veterans’ Appeals (Board) on appeal from March 2014 and November 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office in Phoenix, Arizona, which denied the benefits being sought. These matters were before the Board in April 2017 and were remanded for further development. The Board finds that there has been substantial compliance with its remand directives. Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The issues of service connection for bilateral hearing loss and tinnitus were again remanded by the Board in April 2018, for further development. The current record contains an April 2018 dated Memorandum of Formal Finding on the Unavailability of STRs. The memorandum notes that an August 2013 request was made to the National Personnel Records Center and a negative reply was received, as well as notation indicating that the STRs were destroyed in a fire. The memorandum also indicated that phone calls were made to the Veteran on September 11, 2017, December 19, 2017, and January 9, 2018, regarding the missing STRs, and he stated that he did not go to the military hospital or a civilian hospital while in the military. Further, a development letter with NA Form 13055, was submitted by the Veteran in December 2017, in which he noted that “[a]ll medical records were sent to you by Attorney.” The Board notes that regarding the April 2018 Memorandum of Formal Finding, the Veteran has since been notified of said findings. As the STRs are unavailable, due to no fault of the Veteran, there is a heightened obligation on the part of VA to explain findings and conclusions and to consider carefully the benefit-of-the-doubt rule. Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board’s analysis, in this case, has been undertaken with the heightened obligation outlined in Cuevas and O’Hare in mind. It is noted, however, that the case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board’s obligation to evaluate and discuss in its decision, all of the evidence that may be favorable to the claimant. Russo v. Brown, 9 Vet. App. 46 (1996). The Veteran through his agent has argued that the VA examinations of January 2018, relating to the Veteran’s service connection claims to be inadequate because the examiner did not specifically address Dr. M. E.’s favorable opinion. The examiner’s lack of discussion of Dr. M. E.’s opinion does not render the examination inadequate. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012) (Stating that there is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file.) His agent also argued that the negative opinions contained only conclusory statements. The Board, however, finds the January 2018 VA examinations are adequate for adjudication purposes. The examiner reviewed the claims file, interviewed the Veteran, and provided a rationale for the opinions provided, as will be discussed below. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The January 2018 VA examinations for bilateral hip and bilateral knee disorders are agreeably inadequate and those claims are remanded for additional development. This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2017). If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity for certain diseases. 38 C.F.R. §§ 3.303 (a), (b), 3.309 (a) (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 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) (2017). To establish service connection for the claimed disorder, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303 (2017); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The requirement of a current disability is “satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim.” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence considering the entirety of the record. The standard of proof to be applied in decisions on claims for veterans’ benefits is outlined in 38 U.S.C. § 5107 (2012). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. 38 C.F.R. § 3.102 (2017). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Service connection for bilateral hearing loss and tinnitus are granted The Veteran seeks to establish service connection for bilateral hearing loss and tinnitus. He maintains that his hearing loss disability and tinnitus began in service and had continued since. Specifically, he avers that while serving in Korea as a field artillery operations and intelligence specialist, he was struck by lightning at his post atop a mountain, while on the phone. The power from the lightning hit the phone and ran into his right ear, like “a hammer nailed [him] straight into the ground.” This was the first of two lightning strikes he sustained in service. Specific to claims for service connection for hearing loss, impaired hearing is considered a “disability” for VA purposes only when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC test are less than 94 percent. 38 C.F.R. § 3.385. The threshold for normal hearing is between 0 and 20 decibels, and higher thresholds show some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). There is no dispute that the Veteran has a current bilateral sensorineural hearing loss disability as defined by VA regulations. Both the VA Disability Benefits Questionnaire (DBQ), dated in February 2014, and the private audiometric test conducted by Dr. B. S. R. in May 2013, reflect that the Veteran has auditory thresholds of 40 decibels and above in the left ear at 2000 and 4000 Hertz; the right ear at 1000, 2000, 3000, and 4000 Hertz. The Veteran’s hearing loss meets the criteria to be considered a disability for VA purposes. 38 C.F.R. § 3.385 (2017). Thus, the first element of a service connection claim is satisfied with regard to bilateral hearing loss. Shedden, 381 F.3d at 1166-67. Tinnitus is a condition that is capable of lay observation, and the Veteran’s reports of ringing in his ears are credible. Charles v. Principi, 16 Vet. App. 370 (2002). The first element of a service connection claim is satisfied with regard to tinnitus. The Veteran provided lay statements that he was exposed to artillery noise without the use of ear protection. He also contended that he was struck by lightning twice during his military service while listening on a wired radio to report a sighting. He noticed decreased hearing afterward. His DD Form 214 reflects that his most significant duty assignment was as field artillery operations and intelligence specialist and that he received the Korean Service Medal. The Board finds that the Veteran was exposed to excessive noise in service. The Board also finds the Veteran’s statements regarding his in-service noise exposure, the onset of hearing loss and the ringing in his ears to be both competent and credible. Layno v. Brown, 6 Vet. App. 465 (1994). The second element of a service connection claim is satisfied concerning both issues. Shedden, 381 F.3d at 1166-67. The Veteran has continuously held that his hearing loss began in service and he has experienced the continuity of symptoms since then. He had provided the lay statement from his wife who states that when he came home from service, “we had to keep repeating [things] to him.” The Veteran has also provided lay statements that he was a painter for 31 years, and although he was exposed to compressor noise, he wore ear protection. He reported no noisy hobbies after service. As hearing loss is a chronic condition as outlined in 38 C.F.R. § 3.309 (a), the theory of the continuity of symptomatology is applicable. 38 C.F.R. § 3.303 (a), (b) (2017); Walker, 708 F.3d 1331. The probative evidence of record is void of any concurrent causes for the Veteran’s current bilateral hearing loss. The Veteran credibly provided a lay statement that as a painter he wore protection when exposed to compression noise. Regarding tinnitus, there is contradictory evidence of record regarding whether the Veteran has tinnitus. The Veteran in a June 2011 audiology consult the Veteran denied having tinnitus. In his February 2014 VA examination, the examiner concluded that the Veteran did not have tinnitus, for he denied having it. The Veteran’s wife, however, Y. L., has provided statements that during the examination, the Veteran “likely did not know what tinnitus was or understood what was being asked.” Nonetheless, the record contains a private audiology assessment of May 2013, by Dr. B. S. R., which found that the Veteran did have tinnitus associated with his hearing loss. Tinnitus is considered an “organic disease of the nervous system” under 38 C.F.R. § 3.309 (a). Fountain v. McDonald, 27 Vet. App. 258, 275-75 (2015). As tinnitus is recognized as a chronic disease, it can be service-connected based on continuity of symptomatology alone, without a medical nexus opinion. The Veteran has competently and credibly stated that he had experienced tinnitus since service. Charles, 16 Vet. App. 370. Therefore, the theory of the continuity of symptomatology is also applicable with regard to tinnitus. 38 C.F.R. § 3.303 (a), (b); Walker, 708 F.3d 1331 (Fed. Cir. 2013). A grant based on the continuity of symptomatology is warranted for tinnitus. The Board has considered the totality of the evidence, including the nature of the Veteran’s service, his credible statements of onset and continuity of hearing loss and tinnitus, and his wife’s statements. The favorable lay evidence, combined with Dr. B. S. R.’s opinion, is afforded high probative weight. The preponderance of the evidence is in favor of service connection for tinnitus and bilateral hearing loss. 38 U.S.C. § 5107 (b) (2017). The appeals are, therefore, granted. 2. Service connection for a heart condition, allergy disorder, memory loss disorder, sleep disorder, and an acquired psychiatric or neurocognitive disorder are denied The Veteran contends that he was struck by lightning twice in service which then caused his heart condition, allergy disorder, memory loss disorder, sleep disorder, an acquired psychiatric or neurocognitive disorder. The Board notes that there are no STRs of record to support his contention. The record reflects that the STRs are unavailable. The record also shows that phone calls were made to the Veteran on September 11, 2017, December 19, 2017, and January 9, 2018, and he stated that he did not go to the military hospital or a civilian hospital while in the military. However, the Board finds that the Veteran’s statements that the lightning strikes occurred to be credible, as discussed above. In January 2018, the Veteran was afforded VA examinations to determine the etiology of his claimed disabilities. Regarding the heart condition, the January 2018 examiner diagnosed the Veteran with coronary artery disease (CAD) and s/p aortic valve replacement for aortic stenosis and opined that the conditions were less likely as not incurred in or causally or etiologically related to his military service. In arriving at his conclusion, the examiner explained that: [t]he [V]eteran’s report of [two] episodes of electrical injury due to lightning and extensive walking up and down hills during service is accepted as accurate statements and is considered … The Veteran’s report of a heart murmur being discovered soon after separation is considered. Lightning strikes may cause severe injuries to various parts of the body depending on the amount of thermal energy absorbed and to which parts of the body. These injuries, however, are unlikely to be silent for many years. Deep electrothermal injury can result in tissue necrosis, edema, and permanent scarring. Such injuries will most likely be apparent initially with significant associated symptoms. Although lightning strikes may cause sudden cardiac death and myocardial injuries, in [a] review of medical literature, I find no evidence of a causative nexus to aortic stenosis or coronary artery disease. In summary, after careful review of the available record, I find insufficient evidence of a causative link between the claimed condition and the [V]eteran’s military service. Regarding his service connection claim for allergies, the Veteran reported to the examiner that in the past 10-20 years, he began having allergies. The examiner noted that the Veteran did not give a history of the relationship between service and the development of allergies. The examiner diagnosed allergic rhinitis and a history of chronic sinusitis and opined that his allergic rhinitis, history of chronic sinusitis, were less likely as not incurred in or causally or etiologically related to his military service. The examiner noted that he considered the “lack of history of sinus/allergy symptoms during and for years after service.” He explained that although lightning strikes may cause severe injuries to various parts of the body, depending on the amount of thermal energy absorbed and to which parts of the body, these injuries, however, are unlikely to be silent for many years. In summary, after careful review of the available record, I find insufficient evidence of a causative link between the claimed condition and the Veteran’s military service. In support of his opinions regarding an allergy disorder and a heart disorder, the examiner referenced UpToDate, Environmental and weapon-related electrical injuries and Natural history, epidemiology, and prognosis of aortic stenosis. The Veteran also underwent a VA examination in January 2018 for his memory loss disorder, sleep disorder, an acquired psychiatric or neurocognitive disorder. The examiner noted the following symptoms that actively apply to the Veteran’s diagnoses: chronic sleep impairment, impairment of short and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks, flattened affect, impaired impulse control, such as unprovoked irritability with periods of violence and disorientation to time or place. The examiner then concluded that it was less likely than not that his current psychiatric and neurocognitive symptoms were due to the lightning strikes incurred during service. Regarding the unspecified neurocognitive disorder, the examiner noted that the Veteran met all DSM-5 diagnostic criteria for diagnosis of unspecified neurocognitive disorder. However, other DSM-5 diagnostic criteria were not met. His “current symptoms” of memory loss and insomnia were symptomatic of his neurocognitive disorder and did not rise to the level of an additional diagnosis or disorder “at [the] time” of examination. He did not present with evidence of a psychotic disorder. The examiner also found that the Veteran did not have PTSD. Regarding memory loss, the examiner explained that [t]here is no temporal connection between the indirect lightning strike in 1953 and the onset of his memory problems in 1997, some 44 years later. There is no medical literature [to] suggest [the] delayed onset of symptoms 44 years following a lightning strike. There is no medical evidence [that] would suggest that there would be progressive deterioration in memory following [the] delayed onset of memory impairment. There is no medical literature there [to] suggest an absence of symptoms of memory problems for 44 years with subsequent acute onset. Regarding sleep impairment, the examiner explained that [t]here is no temporal connection between the indirect lightning strike in 1953 and the onset of his sleep problems in 2015; some 62 years later. There is no medical literature [to] suggest [the] delayed onset of sleep disorder 62 years following an indirect lightning strike. There is no medical literature [to] suggest [the] absence of symptoms of sleep disorder for 62 years with a then acute manifestation. The examiner found that the Veteran did not have a psychotic disorder, NOS. Additionally, the examiner explained that there was no temporal connection between the indirect lightning strike in 1953 and the onset of the claimed psychotic disorder in 2015. His current symptoms as reported, [includes thinking] there is someone in the house when he [is] alone, do not meet the f[u]ll DSM-5 diagnostic criteria for the diagnosis of psychotic disorder unspecified. There is no medical literature [to] suggest an onset of psychotic symptoms 62 years later after [the] lightning strike. There is no medical evidence that symptoms a psychotic disorder would be absent for 62 years and then manifest themselves that 62 years later. The opinions provided by the January 2018 VA examiners were formed after a thorough review of the Veteran’s available post-service treatment records, electronic claims file, an interview with the Veteran, and clinical examinations. The examiners supported their conclusions with thorough rationales. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board, therefore, accords the January 2018 VA opinions the most probative weight in a finding that the Veteran’s heart disorder, allergy disorder, memory loss disorder, sleep disorder, an acquired psychotic disorder, NOS were incurred in service. In support of his claims for service connection, the Veteran provided positive nexus from Dr. M. E., dated in May 2014. Dr. M. E. stated that the Veteran had “…multiple MRI infarcts, documented mild memory loss … from military associated lightening strikes when he ran an old style wired telephone as an advanced recon soldier in the hills near the DMZ soon after the Korean conflict.” Dr. M. E. opined that the Veteran “is entirely disabled, and some of it is more likely than not service connect[able].” Dr. M. E. offered a conclusory opinion without any underlying explanation or supportable rationale. He did not explain why the MRI infarcts or memory loss were due to the lightning strikes. A medical report “must be read as a whole” to determine an examiner’s rationale. Monzingo, 26 Vet. App. 97 (2012). In this case, it is not possible to determine Dr. M. E.’s reasoning from his statement. The Board finds this opinion less probative than the VA medical opinions of January 2018. After the January 2018 medical opinions, the Veteran through his agent provided additional medical treatises, from PTSD Quarterly Research: Mental Health Effects of Natural and Human Disasters; Lightning and the Nervous System; Lightning-Associated Injuries and Death Among Military Personnel - United States, 1998-2001; Lightning Strike A Rare Cause of Bilateral Ossicular Disruption; and Pathological Features of Death From Lightning Strike. The Board notes that medical treatise evidence can, in some circumstances, constitute competent medical evidence. 38 C.F.R. § 3.159 (a)(1) (2017). It can provide important support when combined with an opinion of a medical professional if the article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least “plausible causality” based on objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); Wallin v. West, 11 Vet. App. 509 (1998). Generic medical literature which does not apply medical principles regarding causation or etiology to the facts of an individual case does not provide competent evidence to establish a nexus. Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The exception to this competency rule is when the medical treatise information, where “standing alone, discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion.” Wallin, 11 Vet. App. 509. In this case, the treatises submitted by the Veteran are not accompanied by a medical opinion that purports conclusively to show that the Veteran’s heart disorder, allergy disorder, memory loss disorder, sleep disorder, an acquired psychotic disorder, NOS were caused by service or any incidents therein, to include being struck twice by lightning. Here, there is no supporting medical evidence that the general principles cited in the treatises relate to the specific situation of the Veteran in this case. Mattern v. West, 12 Vet. App. 222, 228 (1999). The Board finds that the treatises submitted in this case do not meet the standard as outlined in Wallin. Hence, they are less probative than the findings of the January 2018 VA examiners. The Board has considered the Veteran’s reported a history of symptomatology related to his heart disorder, allergy disorder, memory loss disorder, sleep disorder, and an acquired psychiatric or neurocognitive disorder. He is competent to report observable symptoms. Layno, 6 Vet. App. 465, 470 (1994). His statements are credible. Determining whether these disabilities are related to service or his in-service lightning strikes, requires medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran, who in this case, has not been shown by the evidence of record to have the training, experience, or skills needed to provide a competent etiology opinion on these complicated matters. As a result, his lay opinions are less probative than the well-reasoned opinions of the January 2018 VA examiners. The most probative evidence of record does not support service connection for the Veteran’s heart disorder, allergy disorder, memory loss disorder, sleep disorder, and an acquired psychiatric or neurocognitive disorder. The preponderance of the probative evidence of record weighs against the claims. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. See 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). REASONS FOR REMAND Service connection for a bilateral knee and bilateral hip condition is remanded The Board finds that additional development is needed before the Veteran’s claims for service connection for bilateral hip disability and bilateral knee disability. The Veteran was provided a VA examination for his bilateral knee and bilateral hip disabilities in January 2018. Regarding his knees, the examiner noted that the Veteran did a lot of walking up and down hills in service, as well as hiking after service. He also noted that the Veteran had episodes of stiff knees in the morning for “about 10 years” and has occasionally had knee swelling, both before, and after service. Regarding service connection for the hips, the Veteran reported no memory of the history of injuries to his hips during his lifetime. He, however, reported having to walk up and down steep hills in Korea and quite a bit of hiking after service. The examiner noted that the Veteran’s wife of 65 years reported that both hips began bothering him in the 1960’s, but he began having trouble walking in general, about 10 years ago. The examiner concluded that “[b]ased on his age and physical findings, the [V]eteran most likely has DJD of both knees and hips, but this has not been documented by X-ray findings, so internal derangement is used as a diagnosis.” As the Board finds that the opinion is incomplete, a remand is necessary to provide a supplemental opinion to determine the exact nature of his bilateral hip and bilateral knee disabilities. Accordingly, the matters are REMANDED for the following action: This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). 1. Provide the Veteran’s claims file to an appropriate clinician to provide a supplemental opinion regarding the Veteran’s bilateral knee disabilities. The entire claims file and a copy of this remand must be made available to the examiner for review. If the clinician determines that imaging studies are required before an opinion can be provided, such testing should be scheduled. Although an independent review of the claims file is required, the examiner’s attention is drawn to the following: a. The Veteran’s wife’s assertion that his knees bothered him beginning in the 1960s. b. The April 2018 Memorandum of Formal Finding on the Unavailability of STRs. Lack of documentation of symptoms in service cannot be the basis for a negative opinion. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral knee disability began during active service; or is related to an incident of service; or if arthritis is diagnosed, began within one year after discharge from service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Provide the Veteran’s claims file to an appropriate clinician to provide a supplemental opinion regarding the Veteran’s bilateral hip disabilities. The entire claims file and a copy of this remand must be made available to the examiner for review. If the clinician determines that imaging studies are required before an opinion can be provided, such testing should be scheduled. The examiner’s attention is drawn to the April 2018 Memorandum of Formal Finding on the Unavailability of STRs. Lack of documentation of symptoms in service cannot be the basis for a negative opinion. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s bilateral hip disability began during active service; or is related to an incident of service; or if arthritis is diagnosed, began within one year after discharge from service. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Then, readjudicate the claims. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Stevens, Associate Counsel