Citation Nr: 18148993 Decision Date: 11/08/18 Archive Date: 11/08/18 DOCKET NO. 16-29 211 DATE: November 8, 2018 ORDER Service connection for a psychiatric disorder, diagnosed as an adjustment disorder and Major depressive disorder, is granted. Service connection for peripheral neuropathy of the bilateral upper and lower extremities is granted. Service connection for right ear hearing loss is denied. A compensable rating for left ear hearing loss is denied. An effective date earlier than June 17, 2016, for the award of service connection for left ear hearing loss is denied. An effective date earlier than June 17, 2016, for the award of service connection for tinnitus is denied. REMANDED The issue of entitlement to service connection for osteoporosis is remanded. The issue of entitlement to service connection for a vascular condition, claimed as blood clots, is remanded. The issue of entitlement to service connection for sleep apnea is remanded. The issue of entitlement to service connection for a heart condition is remanded. The issue of entitlement to service connection for hypertension is remanded. The issue of entitlement to service connection for right testicle removal is remanded. FINDINGS OF FACT 1. The Veteran has a current psychiatric disorder, diagnosed as Major depressive disorder (MDD) and adjustment disorder, secondary to service-connected multiple myeloma. 2. The Veteran has peripheral neuropathy of the bilateral upper and lower extremities secondary to service-connected multiple myeloma and its treatment. 3. The Veteran does not have a right ear hearing loss disability for VA purposes. 4. The most probative evidence indicates the Veteran’s left ear hearing loss has been manifested by, at worst, Level II hearing loss. 5. The Veteran filed claims of entitlement to service connection for hearing loss and tinnitus that were denied by a February 1998 rating decision; he did not perfect an appeal of that decision or submit relevant evidence within one year of notification of the decision. 6. VA next received correspondence from the Veteran regarding entitlement to service connection for hearing loss and tinnitus on June 17, 2016. CONCLUSIONS OF LAW 1. The criteria for service connection for a psychiatric disorder as secondary to service-connected multiple myeloma are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for service connection for peripheral neuropathy of the bilateral upper and lower extremities as secondary to a service-connected multiple myeloma are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for service connection for a right ear hearing loss disability are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.385. 4. The criteria for an initial compensable evaluation for left ear hearing loss are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.85, Diagnostic Code 6100. 5. The criteria for an effective date earlier than June 17, 2016, for the grant of service connection for left ear hearing loss are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 6. The criteria for an effective date earlier than June 17, 2016, for the grant of service connection for tinnitus are not met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1974 to November 1978. This matter comes before the Board on appeal from February 2014, March 2015, and August 2016 rating decisions. The issues of entitlement to service connection for right ear hearing loss, a psychiatric disorder, and right testicle removal were previously denied by the RO in February 1998 and/or December 2002 rating decisions. The Board finds that new and material evidence has been submitted to reopen those claims and they will be addressed on the merits below. Further, to the extent that the right testicle removal claim has not yet been certified to the Board for appellate review, the Board observes that the Veteran perfected his appeal on that issue in December 2017, and it does not appear that any action has been taken on the appeal since. Thus, the Board is assuming jurisdiction over that issue at this time. As a final matter, the Board observes that the Veteran’s attorney has repeatedly submitted waivers of consideration of evidence by the RO, and in November 2017 and October 2018 correspondence, indicated that for each relevant appeal stream, the argument was “our final submission,” that the Veteran was waiving any additional time to submit additional evidence or argument, and requested that the case be forwarded to the Board for a decision. Thus, the Board will proceed with adjudication of the appeal. 1. Service Connection for a Psychiatric Disorder and Peripheral Neuropathy of the Bilateral Upper and Lower Extremities The Veteran seeks service connection for a psychiatric disorder and peripheral neuropathy of the bilateral upper and lower extremities, to include as a result of his service-connected multiple myeloma. Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). Turning first to the psychiatric claim, VA treatment records show that the Veteran has been diagnosed with and treated for a psychiatric disorder variously diagnosed as adjustment disorder, adjustment disorder with mixed anxiety and depressed mood, and MDD, to include as recently as June 2018. While a May 2015 VA examiner found that no psychiatric diagnosis was warranted following examination of the Veteran, the Board finds that conclusion not probative as it is entirely inconsistent with ongoing VA treatment notes dating from 2012 through 2018 showing mental health treatment for MDD, chronic depression, and/or an adjustment disorder, and active medication prescribed for depression and mood throughout that period. See also McClain v. Nicholson, 21 Vet. App. 319 (2007) (holding that the requirement of a current disability is satisfied when a claimant has a disability at the time a claim of entitlement to disability compensation is filed or during the pendency of that claim). Furthermore, the evidence shows that the Veteran’s psychiatric disorder and its symptoms, including depression, tearfulness, sleep impairment, depression, and anxiety, are related to his multiple myeloma. For instance, in April 2012, it was noted that the Veteran appeared to be experiencing a mix of mild-moderate anxiety and depressive symptoms regarding his diagnosis and treatment, and he was assessed with an adjustment disorder with mixed anxiety/depression. It was also noted that month that he appeared more distressed “likely due to increased difficulty with neuropathic pain and disrupted sleep.” In May 2017, it was noted that the Veteran had a depressed mood and “continues to have some worry about his prognosis,” and in August 2017, he “continue[d] to have thoughts/fears of death related to his cancer.” More recently, in March 2018, he was “bothered by diminished energy and amotivation.” Significantly, there is no opinion of record attributing the Veteran’s psychiatric disorder to another cause during the appeal period, and, while the Veteran admittedly discussed periodic situational stressors during his ongoing mental health treatment, the record overwhelmingly shows that the Veteran’s psychiatric problems were secondary, in large part, to his multiple myeloma. Upon review of all the evidence of record, the Board finds that the evidence weighs in favor of a finding that the Veteran’s psychiatric disorder is secondary to his service-connected multiple myeloma disability. For these reasons, service connection for a psychiatric disorder, to include MDD and an adjustment disorder, is warranted. Next, the Board finds that service connection for neuropathy of the bilateral upper and lower extremities is also warranted secondary to multiple myeloma and its treatment. In this regard, VA treatment notes dated in April 2012 show that the Veteran began experiencing burning sensations in his legs and tingling in his hands soon after being diagnosed with multiple myeloma and was noted to have “neuropathy from his chemotherapy.” He was thereafter noted to have “developed peripheral neuropathy due to chemotherapy for his multiple myeloma” in November 2012 and July 2013 and, in March 2015, was noted to have “neuropathy secondary to his multiple myeloma condition.” It is also observed that his chemotherapy medications were held or adjusted at times due to neuropathic symptoms, including in January 2014. The Board recognizes that a May 2017 provider noted that the Veteran’s “diabetes leaves him with neuropathy in his feet.” However, the Board observes that the record does not otherwise support that the Veteran actually had diabetes, at least not prior to May 2017. In this regard, diabetes was not noted on the Veteran’s active problem list prior to that date, the record does not show medication prescribed for diabetes, and, in February 2014, in assessing the Veteran’s cardiac risk factors, it was noted “No Diabetes.” In any event, regardless of any potential contribution from diabetes, the record still otherwise establishes that the Veteran has neuropathy of the bilateral upper and lower extremities secondary to his multiple myeloma and the chemotherapy use to treat it. Thus, the Board finds that the evidence weighs in favor of a finding that the Veteran’s neuropathy of his bilateral upper and lower extremities is secondary to his service-connected multiple myeloma disability, and, as a result, service connection is warranted. 2. Service Connection for Right Ear Hearing Loss The Veteran seeks service connection for right ear hearing loss, which he asserts was incurred during service as a result of noise exposure from rifle fire. Service connection may be established 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. Regulations also provide that service connection is warranted for a disease first 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). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service precipitating disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the current disability and the in-service event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Following a review of the record, the Board finds that the Veteran does not have a right ear hearing loss disability for VA purposes. In this regard, a July 2016 VA audiological examination revealed no pure tone thresholds higher than 20 decibels at any frequency tested for the right ear, except for a 25-decibel threshold at 8000 Hertz. Additionally, speech recognition for the right ear was 96 percent. See 38 C.F.R. § 3.385 (explaining that impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent). Further, there is no assertion by the Veteran, or medical records in the claims file, indicating a worsening of the Veteran’s right ear hearing loss to the point where he would have a hearing loss disability as recognized under 38 C.F.R. § 3.385. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Indeed, during VA treatment both prior and subsequent to the July 2016 VA examination, the Veteran affirmatively denied hearing loss or hearing changes or was noted to have intact hearing, including in February 2014, November 2017, and April 2018. As a result, the Board must deny the claim for service connection for right ear hearing loss. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). 3. Increased Rating for Left Ear Hearing Loss The Veteran seeks an initial compensable evaluation for bilateral hearing loss. After review of the record, however, the Board finds that an increased initial evaluation is not warranted for left ear hearing loss at any time during the appeal period. Here, the only audiometric findings valid for rating purposes during the relevant period on appeal come from a July 2016 VA examination. The audiogram conducted during the July 2016 examination showed pure tone thresholds of 10, 25, 30, and 40 decibels in the left ear at 1000, 2000, 3000, and 4000 Hertz (“specified frequencies”). The average pure tone threshold was 26 decibels in the left ear, and speech audiometry revealed speech recognition ability of 90 percent in the left ear. Applying the results from that examination to Table VI in 38 C.F.R. § 4.85 yields a finding of Level II hearing loss in the left ear. And, in cases, such as this one, where only one ear is service-connected for hearing loss, the nonservice-connected ear’s hearing impairment is evaluated as Level I for purposes of reading Table VII. See 38 C.F.R. § 4.85(f). Thus, throughout the appeal, the Veteran’s right ear is assigned Level I hearing acuity. Where hearing loss is at Level I in the better ear, and Level II in the poorer ear, a noncompensable rating is assigned under Table VII. While the Board sympathizes with the Veteran, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). Here, the audiometric testing during the appeal period does not support a compensable rating at any time. Moreover, as noted above, during VA treatment both prior and subsequent to the July 2016 VA examination, the Veteran affirmatively denied hearing loss or hearing changes or was noted to have intact hearing, including in February 2014, November 2017, and April 2018. Thus, the Board finds that a new examination is not warranted. The Veteran also did not otherwise report during the appeal period any significant functional impact from his hearing loss beyond “dizziness and…unable to keep my balance.” To that end, there is nothing in the record to support that any dizziness or balance issues the Veteran may have had were in any way related to hearing loss. Indeed, with limited exception, the Veteran generally denied dizziness during ongoing VA treatment during the appeal period, and, when dizziness or unsteadiness was reported, such as in May 2012 or February 2014, it was not in the context of or in any way assessed to be related to hearing loss. Even further, VA treatment notes are essentially silent for complaints related to hearing loss during the appeal period, and there is no evidence that hearing aids have been required or prescribed at any point. The Board finds that the Veteran’s functional impairment due to left ear hearing loss is a disability picture that is specifically and adequately contemplated by the current schedular rating criteria. See Doucette v. Shulkin, 28 Vet. App. at 369-70 (finding that the rating criteria for hearing loss contemplate the functional effects of decreased hearing and difficulty understanding speech in an everyday work environment, as these are the effects that VA’s audiometric tests are designed to measure). In summary, the most probative evidence of record fails to demonstrate that an initial compensable rating is warranted for left ear hearing loss. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). 4. Earlier Effective Dates for Service Connection for Left Ear Hearing Loss and Tinnitus The Veteran contends that he is entitled to effective dates earlier than June 17, 2016, for the grants of service connection for left ear hearing loss and tinnitus. After a review of the evidence of record, the Board disagrees. Except as otherwise provided, the effective date of the award of an evaluation based on an original claim, a claim reopened after a final disallowance, or a claim for an increase will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. By way of history, the Veteran filed informal claims of entitlement to service connection for tinnitus and hearing loss in March 1982. Those claims were ultimately closed in July 1982 due to the Veteran’s failure to prosecute, or, specifically, due to his failure to complete an initial formal application for benefits (VA Form 21-526), or submit evidence in support of his claims, as requested in May 1982 correspondence. Then, in January 1997, the Veteran filed new informal hearing loss and tinnitus claims, and, in March 1997, he completed a formal application, VA Form 21-526. In a February 1998 rating decision, the RO denied the hearing loss and tinnitus claims. The Veteran next filed to reopen the claims of entitlement to service connection for hearing loss and tinnitus in June 2016, and the RO subsequently reopened and granted service connection for tinnitus and left ear hearing loss, both effective June 17, 2016, the date of receipt of his 2016 claims to reopen. The Veteran has not presented specific arguments for why he believes that earlier effective dates are warranted. To the extent that he believes that earlier claims filed for tinnitus and hearing loss could serve as the basis for an earlier award, the Board will address why they cannot. Initially, as the March 1982 informal claims for hearing loss and tinnitus were not followed by the filing of a formal claim within one year after VA sent the formal application form, their receipt date cannot serve as the basis for earlier effective dates. 38 C.F.R. § 3.155 (2009) (“Upon receipt of an informal claim..., an application form will be forwarded to the claimant....If received within 1 year from the date it was sent to the claimant, it will be considered filed as of the date of receipt of the informal claim.”). In contrast, the January 1997 informal service connection claims for hearing loss and tinnitus were followed by the filing of a formal VA application for benefits within one year (in March 1997) and thus, could be considered as claims for purposes of assigning effective dates. However, the Board finds that the January 1997 claims were finally denied by a February 1998 rating decision, even considering evidence that the rating decision was initially returned as undeliverable in March 1998. In this regard, after the notice letter and rating decision mailed to the Veteran at a VA domiciliary were returned, the RO made efforts to confirm or locate a new address for the Veteran, including reaching out to the Veteran’s service representative, and ultimately located a new address in VA’s Automated Medical Information Exchange (AMIE). See Woods v. Gober, 14 Vet. App. 214, 220-21 (2000); Hyson v. Brown, 5 Vet. App. 262, 264 (1993). Moreover, there is no evidence that the re-sent letter with rating decision were returned as undeliverable, and the record elsewhere shows the Veteran’s use of the address both prior and subsequent to the February 1998 rating decision, including in January 1997 and December 2001. The Board also points out that January 2002 correspondence to the Veteran referenced the February 1998 rating decision in the context of new and material evidence needed for another claim, and the Veteran offered no challenge to receipt or knowledge of that decision. Thus, the Board finds that the Veteran was properly notified of the February 1998 rating decision. As no new and material evidence was received within one year of the February 1998 rating decision being resent in April 1998, and because the Veteran did not appeal, the rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.200, 20.202, 20.1103; Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). As such, the Veteran’s previously-denied January 1997 claims of entitlement to service connection tinnitus and hearing loss cannot serve as the basis for earlier effective dates. The Board is sympathetic to the Veteran’s situation, but concludes that the February 1998 rating decision became final, that there was no formal or informal application to reopen the hearing loss or tinnitus claims received prior to June 17, 2016, and there is no claim for CUE on appeal. As a result, the appropriate effective date for the grants of service connection for tinnitus and left ear hearing loss is June 17, 2016, the date of receipt of his reopened claims. See 38 C.F.R. § 3.400(q)(2),(r). REASONS FOR REMAND 1. The issues of entitlement to service connection for osteoporosis, a vascular condition (claimed as blood clots), a heart condition, hypertension, and sleep apnea are remanded. Although the Veteran has been afforded a VA examination generally related to his multiple myeloma, he has not been afforded examinations related to his secondary claims, with the exception of sleep apnea. In this regard, the record shows that the Veteran has “extensive bony disease,” chronic venous embolism and thrombosis, deep vein thrombosis of the lower extremities, coronary artery disease, status post myocardial infarction, hypertension, chronic orthostatic hypotension, and sleep apnea, which may be associated with his multiple myeloma or its treatment. As such, the Board finds that examinations and opinions are necessary. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Board acknowledges that a medical opinion regarding sleep apnea was obtained in November 2016, at which time an examiner concluded that it would be speculation to state that the Veteran’s symptoms of being tired and worn down in service were related to sleep apnea. However, the examiner provided no explanation for why an opinion would be speculative, nor did the examiner address secondary service connection. In this regard, in January 2015, it was noted that the Veteran had “possible opioid induced” central sleep apnea, and the record reflects that the Veteran is prescribed opioids for his multiple myeloma-associated pains. The examiner also did not address whether the Veteran had obstructive sleep apnea or a circadian phase disorder, as indicated in a January 2015 VA treatment note, that were related to service or service-connected multiple myeloma. Thus, a new opinion is necessary. On remand, updated and outstanding treatment notes should be obtained. 2. The issue of entitlement to service connection for removal of the right testicle is remanded. The Board finds that remand of the Veteran’s right testicle claim is necessary to obtain outstanding records and for an addendum opinion. In this regard, in December 1997, in connection with the Veteran’s original claim, a VA examiner found that the Veteran’s right epididymitis “absolutely [did] not” contribute to his right orchiectomy (testicle removal). Then, in connection with the current appeal, a VA examiner opined in May 2017 and July 2017 that the Veteran’s right testicle removal was not related to multiple myeloma, but rather, tuberculosis of the testicle. Initially, it is unclear where and when the Veteran was diagnosed with testicular tuberculosis, as the currently-associated treatment notes related to his 1996 orchiectomy do not show a diagnosis of tuberculosis. Instead, the record merely references the Veteran’s reports that he was diagnosed with that condition, and the examiner’s finding, without documentation. Thus, remand is necessary to obtain records related to the diagnosis of testicular tuberculosis. Additionally, the Board observes that service treatment records show treatment for right scrotal/testicular pain diagnosed as epididymitis, to include in August 1976. Additionally, a post-service VA examination in August 1979 noted recurrent epididymitis, and post-service treatment records show treatment for right epididymitis in February 1979 and November 1981. Indeed, the Veteran has been service connected for recurrent right epididymitis. The Board also notes that in August 1979, the Veteran underwent a chest x-ray, the report of which noted recurrent epididymitis and no evidence of pulmonary tuberculosis at that time. According to UpToDate, epididymitis is the most common clinical manifestation among men with genital tuberculosis, and the average period between pulmonary infection and clinical manifestations of urogenital tuberculosis is 22 years. See https://www.uptodate.com/contents/urogenital-tuberculosis?search=testicular%20tuberculosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1. Given the foregoing, the Board finds that an addendum opinion is necessary to address whether the Veteran’s recurrent right epididymitis that began in service was a manifestation of genital (testicular) tuberculosis that led to the right orchiectomy in 1996. The matters are REMANDED for the following action: 1. Request that the Veteran provide or authorize VA to obtain records of his relevant treatment that have not yet been associated with the claims file, to include all outstanding treatment records from private providers who have treated him for testicular tuberculosis, multiple myeloma, osteoporosis, vascular and heart disabilities, hypertension or hypotension, and sleep apnea. Also associate with the claims file updated VA treatment records, any outstanding VA treatment notes related to treatment for testicular tuberculosis or the Veteran’s right testicular mass in the 1990s, and any outstanding records available through the VA medical facilities’ viewing tools (such as Vista Imaging). 2. Then, after the development in item 1 is completed to the extent possible, schedule the Veteran for relevant VA examinations to determine the nature and etiology of any bone, vascular, heart (to include CAD, hypertension, and hypotension), and sleep disabilities. All indicated tests and studies should be conducted and all clinical findings reported in detail. The entire claims file should be made available to and be reviewed by each examiner in conjunction with this request. Following review of the claims file and relevant examination of the Veteran, each examiner should respond to the following, as appropriate: (a) Please identify all current bone, vascular, heart, hypertension/hypotension, and/or sleep disorders. In doing so, please specifically discuss the diagnoses of record, including but not limited to “extensive bony disease,” chronic venous embolism and thrombosis, deep vein thrombosis of the lower extremities, coronary artery disease, status post myocardial infarction, hypertension, chronic orthostatic hypotension, central sleep apnea, obstructive sleep apnea, and circadian phase disorder. In determining whether the Veteran meets the criteria for a specific diagnosis, please consider medical and lay evidence dated both prior to and since the filing of the claims for service connection in September 2014 and June 2016. Please note that, although the Veteran may not meet the criteria for a certain diagnosis at the present time, diagnoses made prior to and since the date of claim filing meet the criteria for a “current” diagnosis. For any diagnoses of record which cannot be validated or confirmed, please explain why such diagnoses cannot be confirmed. (b) For any diagnosed bone, vascular, heart, hypertension/hypotension, or sleep disability found, state whether it at least as likely as not (50 percent probability or more) that the disorder was caused by any service-connected disability, to specifically include his multiple myeloma or treatment for the same (to include, but not limited to, radiation, chemotherapy, or opioids). Please explain why or why not. (c) If not caused by, state whether it is at least as likely as not (50 percent probability or more) that any diagnosed bone, vascular, heart, hypertension or hypotension, or sleep disability has been aggravated by any service-connected disability, to specifically include multiple myeloma or treatment for the same. Please explain why or why not. If you find that any disorder has been aggravated, please attempt to quantify the degree of aggravation beyond the baseline level of disability. (d) For hypertension or any sleep disorder found, if not caused or aggravated by service-connected disability, state whether it is at least as likely as not (50 percent probability or more) that the disorder had its onset in service, within a year of service, or is otherwise related to service. Please explain why or why not, specifically discussing the October 1978 complaints of being tired and worn down in the STRs, as well as the blood pressure readings during separation examination in September 1978 (which appears to be 124/92), and on post-service examination in February 1979 (132/94). A complete rationale for the opinions rendered must be provided. If you cannot provide the requested opinions without resorting to speculation, please expressly indicate this and provide a supporting rationale as to why that is so. 3. Send the claims file to a genitourinary examiner to obtain an addendum opinion regarding the etiology of the Veteran’s right orchiectomy in 1996. The entire claims file should be made available to and be reviewed by the internist in conjunction with this request. Following review of the claims file, he or she should respond to the following: State whether it is at least as likely as not (50 percent probability or more) that the Veteran right orchiectomy was caused or contributed to by his recurrent right epididymitis that had its onset in service. The examiner is asked to specifically discuss whether the Veteran’s right orchiectomy was the result of testicular tuberculosis and, if so, whether the Veteran’s recurrent epididymitis in and post service was an early manifestation of that condition. A complete rationale for the opinion rendered must be provided. If you cannot provide the requested opinion without resorting to speculation, please expressly indicate this and provide a supporting rationale as to why that is so. S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Fagan, Counsel