Citation Nr: 18153124 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 16-58 028 DATE: November 28, 2018 ORDER Entitlement to service connection for type II diabetes is denied. Entitlement to service connection for a thyroid condition is denied. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for a lower back disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a right upper extremity musculoskeletal disability remanded. Entitlement to service connection for a left upper extremity musculoskeletal disability is remanded. Entitlement to service connection for a right lower extremity musculoskeletal disability is remanded. Entitlement to service connection for a left lower extremity musculoskeletal disability is remanded. Entitlement to service connection for a right upper extremity neurological disability is remanded. Entitlement to service connection for a left upper extremity neurological disability is remanded. Entitlement to service connection for a right lower extremity neurological disability is remanded. Entitlement to service connection for a left lower extremity neurological disability is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for a skin disability affecting the bilateral hands, claimed as onychomycosis, is remanded. Entitlement to service connection for a skin disability affecting the bilateral toes, claimed as onychomycosis, is remanded. Entitlement to service connection for asthma is remanded. Entitlement to service connection for rhinitis is remanded. Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for bronchitis is remanded. Entitlement to service connection for headaches is remanded. Entitlement to service connection for an eye disability is remanded. Entitlement to service connection for a dental condition is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to service connection for residuals of a traumatic brain injury (TBI) is remanded. FINDINGS OF FACT 1. There is no evidence that the Veteran’s type II diabetes mellitus originated during service or for many years thereafter, or that it is otherwise etiologically related to service. 2. There is no evidence that the Veteran’s hypothyroidism originated during service or for many years thereafter, or that it is otherwise etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for type II diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for service connection for hypothyroidism have not been met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Introduction The Veteran served on active duty in the United States Army from March 1984 to July 1984, with additional service in the Army National Guard of the Commonwealth of Puerto Rico, to include periods of active duty for training. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The scope of a mental health claim includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The record shows the Veteran’s psychiatric symptoms have been variously diagnosed. Accordingly, the Board refers to the Veteran’s mental health condition(s) broadly, as an acquired psychiatric disorder, herein. The Board acknowledges that the Veteran completed forms in July 2018 and October 2018 opting into VA’s Rapid Appeals Modernization Program (RAMP). A review of the record shows, however, that the Veteran intended to opt into RAMP with respect only to her appeal of increased rating claims that are not the subject of this appeal. Specifically, the Board observes that the Veteran completed a substantive appeal for roughly half of the service connection claims listed above in November 2016, and the appeal of those issues was placed before the Board long before the Veteran was invited in July 2018 to opt into RAMP for the appeal of her increased rating claims. In addition, in her July 2018 substantive appeal relating to the other, approximately half, of the service connection claims listed above, the Veteran stated she wished for those issues to continue to the Board. Based on the foregoing, the Board finds the Veteran has not opted into RAMP with respect to the service connection claims listed above. The Board, therefore, will proceed to address these claims. The increased rating claims which fall under the Veteran’s RAMP appeal will be the subject of a subsequent VA decision, if otherwise in order. Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54 Background and Analysis In September 2015, the Veteran filed a claim for service connection for diabetes and a thyroid condition. She did not specify the date of onset of either condition. The record shows the Veteran has been diagnosed with type II diabetes mellitus and hypothyroidism. The earliest evidence showing these diagnoses is dated in February 2016. Upon a thorough review of the record, there is no documentation of diabetes or thyroid diagnoses or symptoms in the Veteran’s service treatment records (STRs) or post-service records prior to February 2016. To date, the Veteran has not provided any statements or other evidence explaining how her diabetes and/or hypothyroidism may be related to her military service. Again, the Board has carefully reviewed the entire record, and finds there is no evidence indicating the Veteran’s diabetes and/or hypothyroidism manifested during service or for many years thereafter. There is likewise no evidence linking the diabetes and/or hypothyroidism to the Veteran’s service. Instead, the Veteran filed her claims for service connection in September 2015, more than 25 years after her discharge, and the earliest evidence of a diagnosis of either condition is dated in February 2016. Based on the foregoing, the Board finds a preponderance of the evidence weighs against the Veteran’s claims. Accordingly, the claims for service connection for diabetes and hypothyroidism must be denied. The Board acknowledges that the Veteran has not been afforded VA examinations to address her claims. In this regard, VA must provide a medical examination where there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies; and an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability; but insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2017). In this case, the Veteran has been diagnosed with diabetes and hypothyroidism. She has not, however, provided any statement or other evidence suggesting a link between the conditions and her service. For this reason, the Board finds VA is not required to provide a medical examination or examinations in this case. REMAND The Board finds additional development is required before the Veteran’s remaining claims are decided. At the outset, the Board again notes that VA must provide a medical examination where there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies; and an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability; but insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2) (2012); 38 C.F.R. § 3.159(c)(4)(i) (2017). In addition, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Furthermore, a medical examiner is not free to simply ignore a veteran’s lay statements recounting symptoms or events. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Hearing loss and tinnitus The record shows the Veteran has been diagnosed with bilateral hearing loss and tinnitus. She has contended these conditions are related to in-service exposure to acoustic trauma. She has not been afforded a VA examination relating to these claims. Under these circumstances, the Board finds a remand is warranted for a VA examination pursuant to McLendon. Lower back and cervical spine disabilities The record shows the Veteran has been diagnosed with lower back and cervical spine disabilities. In a February 2017 statement, she contended her symptoms had their onset during service due to daily long walks carrying a lot of weight, to include her helmet. The Veteran’s STRs show she complained of back pain in April 1984. She has contended these symptoms persisted to the present day. The Veteran was afforded a VA thoracolumbar spine examination in April 2016. The examiner opined the Veteran’s lower back disability was unrelated to service. Upon review, however, the Board notes the examination took place prior to the Veteran’s filing of the February 2017 statements referenced above. Therefore, the VA examiner did not have the opportunity to review the Veteran’s contentions regarding the etiology of her lower back condition. In addition, the Board observes the Veteran has not been afforded any cervical spine examination. Under these circumstances, the Board finds a remand is warranted for an initial VA cervical spine examination pursuant to McLendon, in addition to a second thoracolumbar spine examination which addresses the Veteran’s contentions. Bilateral upper and lower extremity disabilities The record shows the Veteran has been diagnosed with degenerative joint disease of the shoulders, elbows, and wrists. She has also been diagnosed with bilateral carpal tunnel syndrome, lumbar radiculopathy, and fibromyalgia. The Veteran has also claimed she has a left knee disability related to an in-service injury. Her STRs show she complained of both right and left knee pain during service. The Veteran was afforded VA shoulder and hand/finger examinations in April 2016. The examiner diagnosed left trapezius myositis and left hand/wrist strain, but opined neither condition was related to the Veteran’s service. A review of the examination report shows the examiner did not address the Veteran’s diagnosed bilateral shoulder, elbow, and/or wrist arthritis, which was diagnosed by a private physician in February 2016. Upon a review of the record, the Board observes the Veteran has not been afforded any VA examination to address her bilateral upper and lower extremity neurological diagnoses, which the record indicates may be secondary to her lower back and/or cervical spine disabilities. As the claims for service connection for lower back and cervical spine disabilities are being remanded, the Board finds the claims for service connection for upper and lower extremity neurological disabilities must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). Under the foregoing circumstances, the Board finds a remand is warranted for VA examinations clarifying all upper and lower extremity musculoskeletal and/or neurological diagnoses and addressing their etiologies. Skin disability affecting the bilateral hands and feet The record shows the Veteran has been diagnosed with onychomycosis of the bilateral hands and feet. The Veteran’s STRs show she was treated for in-grown toenails of the bilateral first toes during service. She has contended that around this time, she noticed a fungus in her toenails, and that later, the fungus was also present on her hands. She was afforded a VA skin examination in April 2016. The examiner diagnosed onychomycosis but opined the condition was unrelated to service on the basis that an April 1992 examination report included no complaints of the condition. Upon review, the Board notes the examiner failed to explain why the Veteran’s condition, which was present in service and at the time of the examination in 2016, could not have been dormant at the time of the 1992 examination report he referenced and then manifested again later. In addition, the Board observes the examination report is not clear as to whether the Veteran’s hands were also examined for the condition in question. Under these circumstances, the Board finds a remand is warranted for an additional VA examination. Asthma, rhinitis, sinusitis, and bronchitis The record shows the Veteran has been diagnosed with asthma, rhinitis, sinusitis, and bronchitis. Her STRs show sinusitis was diagnosed in service. The Veteran has contended she developed respiratory problems during basic training. She has not been afforded a VA examination to address these contentions. Under these circumstances, the Board finds a remand is warranted for a VA examination pursuant to McLendon. Headaches The Veteran’s STRs show she reported headaches during service. Her post-service medical records show she has been diagnosed with migraine headaches. In a February 2016 report, a private physician indicated the Veteran’s medical conditions, including her headaches, were related to service, but he provided no explanation in support of his opinion. The Veteran has not been afforded a VA examination to assess the etiology of her headaches. Under these circumstances, the Board finds a remand is warranted for a VA examination pursuant to McLendon. Eye disability The Veteran has been diagnosed with glaucoma. Her STRs show she was treated for eye pain in May 1984. In a February 2016 report, a private physician indicated the Veteran’s medical conditions, including her glaucoma, were related to service, but he provided no explanation in support of his opinion. The Veteran has not been afforded a VA examination to assess the etiology of her glaucoma. Under these circumstances, the Board finds a remand is warranted for a VA examination pursuant to McLendon. Dental condition The Veteran’s Reserve STRs show she was treated for tooth pain in June 1989, which she reported had its onset during a period of active duty for training. In a February 2017 statement, the Veteran made reference to this treatment and indicated that the root of her tooth was currently exposed. She has not been afforded a VA examination to determine the etiology of any present dental condition. Under these circumstances, the Board finds a remand is warranted for a VA examination pursuant to McLendon. Acquired psychiatric disorder The Veteran has been diagnosed with depression, anxiety, posttraumatic stress disorder (PTSD), and insomnia. She has related the onset of her psychiatric symptoms to in-service experiences. She has not been afforded a VA examination to address her contentions. Under these circumstances, the Board finds a remand is warranted for an additional VA examination pursuant to McLendon. Residuals of a traumatic brain injury (TBI) The Veteran has contended she suffers from memory loss. She has attributed her symptoms to an in-service incident in which a tree branch struck her and she lost consciousness. Her STRs and military records confirm the she was struck on the elbow by a tree branch, but do not indicate a loss of consciousness occurred. The Veteran has not been afforded a VA examination to address her contentions. Under these circumstances, the Board finds a remand is warranted for an additional VA examination pursuant to McLendon. The matter is REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Afford the Veteran a VA examination to determine the nature and etiology of her hearing loss and tinnitus. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s right and/or left ear hearing loss originated during or is otherwise etiologically related to her military service, to include claimed in-service exposure to acoustic trauma. Then, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s tinnitus originated during or is otherwise etiologically related to her military service, to include claimed in-service exposure to acoustic trauma. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 3. Afford the Veteran a VA examination to determine the nature and etiology of her lower back disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s lower back disability originated during or is otherwise etiologically related to her military service. In providing his or her opinion, the examiner should address the Veteran’s contention that her lower back disability had its onset during service due to daily long walks carrying a lot of weight. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 4. Afford the Veteran a VA examination to determine the nature and etiology of her cervical spine disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s cervical spine disability originated during or is otherwise etiologically related to her military service. In providing his or her opinion, the examiner should address the Veteran’s contention that her cervical spine disability had its onset during service due to daily long walks carrying a lot of weight, to include her helmet. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Afford the Veteran a VA examination to determine the nature and etiology of all bilateral upper and lower extremity musculoskeletal disabilities present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all bilateral upper and lower extremity musculoskeletal disabilities present during the period of the claim. The examiner should specifically confirm or rule out musculoskeletal disabilities affecting the bilateral hands, wrists, elbows, shoulders, hips, knees, ankles, and feet. Then, with respect to each identified upper and/or lower extremity musculoskeletal disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner should address the Veteran’s STRs showing in-service complaints of hand, elbow, shoulder, and knee pain. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 6. Afford the Veteran a VA examination to determine the nature and etiology of all bilateral upper and lower extremity neurological disabilities present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should confirm or rule out fibromyalgia. Then, with respect to each identified upper and/or lower extremity neurological disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. Then, with respect to each identified upper and/or lower extremity neurological disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability is proximately due to or has been aggravated (permanently worsened beyond its natural progression) by the Veteran’s lower back and/or cervical spine disability. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 7. Afford the Veteran a VA examination to determine the nature and etiology of all skin disabilities present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all skin disabilities present during the period of the claim. The examiner should specifically confirm or rule out onychomycosis affecting the bilateral toes and/or hands. Then, with respect to each identified skin disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner should address the Veteran’s statements to the effect that around the time she was treated for in-grown toenails during service, she observed a fungus that spread from her great toes to all of her toes and, later, to her hands. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 8. Afford the Veteran a VA examination to determine the nature and etiology of her asthma, sinusitis, rhinitis, and bronchitis. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should confirm or rule out asthma, sinusitis, rhinitis, and bronchitis. If the examiner determines the Veteran does not have any of these conditions, he or she should provide a medical explanation of his or her finding. Then, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s asthma, sinusitis, rhinitis, and/or bronchitis originated during or are otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner should address the Veteran’s statements to the effect that she developed respiratory problems during basic training. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 9. Afford the Veteran a VA examination to determine the nature and etiology of her headaches. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s headaches originated during or are otherwise etiologically related to her military service. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 10. Afford the Veteran a VA examination to determine the nature and etiology of any eye disability present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all eye disabilities present during the period of the claim. Then, with respect to each identified eye disability, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the disability originated during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner should address the Veteran’s STRs showing she was treated for eye pain in service. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 11. Afford the Veteran a VA examination to determine the nature and etiology of any dental condition present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all dental conditions present during the period of the claim. Then, with respect to each identified dental condition, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the condition originated during or is otherwise etiologically related to the Veteran’s military service. In providing his or her opinion, the examiner should address the Veteran’s STRs showing she reported tooth pain with an onset during a period of active duty for training, and her statements to the effect that the root of her tooth is exposed. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 12. Afford the Veteran a VA examination to determine the nature and etiology of all acquired psychiatric disorders present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should identify all acquired psychiatric disorders present during the period of the claim. Then, with respect to each identified acquired psychiatric disorder, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the condition originated during or is otherwise etiologically related to the Veteran’s military service. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 13. Afford the Veteran a VA examination to determine the nature and etiology of any residuals of a TBI present during the period of the claim. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated tests and studies should be performed. Following the examination and a review of the relevant records and lay statements, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran experienced a TBI during service. In providing his or her opinion, the examiner should address the Veteran’s contention that she lost consciousness after being struck by a tree branch during a training exercise. If the examiner determines the Veteran did not experience a TBI during service, he or she should provide a medical explanation for this finding. If the examiner determines the Veteran did experience a TBI during service, he or she should identify and assess the severity of all TBI residuals present during the period of the claim. The examiner must provide a rationale for any proffered opinion. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 14. Undertake any other development determined to be warranted. 15. Then, readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate consideration. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Hampton, Associate Counsel