Citation Nr: 20005602 Decision Date: 01/23/20 Archive Date: 01/23/20 DOCKET NO. 16-37 763 DATE: January 23, 2020 ORDER Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for left ear hearing loss is denied. Entitlement to service connection for tinnitus is granted. Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for a low back disability is denied. REMANDED Entitlement to service connection for a gastrointestinal disability, claimed as irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD), is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for deviated nasal septum is remanded. FINDINGS OF FACT 1. At no time prior to the filing of the claim or during the pendency of the claim, does the evidence show the Veteran has manifested a right ear hearing loss disability for VA purposes. 2. Left ear hearing loss was not present in service and is not shown for many years thereafter, and the preponderance of the evidence weighs against a finding that the current left ear hearing loss was incurred during or as a result of service. 3. The lay and medical evidence is at least in relative equipoise as to whether the Veteran’s current tinnitus was incurred in service. 4. The Veteran does not have a current clinically diagnosed left ankle disability; nor does he have any qualifying signs and/or symptoms that may represent an undiagnosed illness or a medically unexplained chronic multi-symptom illness and left ankle pain is not shown to result in functional impairment affecting earning capacity. 5. The Veteran does not have a current clinically diagnosed low back disability; nor does he have any qualifying signs and/or symptoms that may represent an undiagnosed illness or a medically unexplained chronic multi-symptom illness and low back pain is not shown to result in functional impairment affecting earning capacity. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.102, 3.303. 2. Resolving reasonable doubt in the Veteran’s favor, the criteria for entitlement to service connection for tinnitus have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 4. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2005 to July 2009. He testified before the undersigned Veterans Law Judge via video conference in September 2019. A transcript of the hearing is associated with the claims file. Service Connection 1. Entitlement to service connection for bilateral hearing loss The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz 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 Court has held that service connection can be granted for a hearing loss where the Veteran can establish a nexus between his current hearing loss and a disability or injury he suffered while he was in military service. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). The Court has also held that VA regulations do not preclude service connection for a hearing loss which first met VA’s definition of disability after service. Hensley, supra, at 159. The Veteran is seeking service connection for bilateral hearing loss. He has asserted that he was exposed to significant noise as a result of his duties as an infantryman in a combat zone. As an initial matter, the Board observes that the Veteran’s service treatment records (STRs) do not contain any complaints, treatment, or findings related to hearing loss. Indeed, the Veteran’s hearing loss was within normal limits on audiograms conducted throughout his military service, including at entrance into service in July 2005, May 2006, July 2007, and May 2009. See service treatment records. Despite normal audiometric findings during service, including a couple of months prior to his service discharge, the Board finds that the Veteran was exposed to acoustic trauma during service. In this regard, his DD Form 214 and other service personnel records indicate that he served as an infantry assaultman during the Gulf War. Thus, the Board acknowledges the Veteran’s in-service noise exposure. At this juncture, the Board notes that the Veteran has not demonstrated or been diagnosed with right ear hearing loss at any point during the appeal period. The evidence shows, however, that left ear hearing loss was demonstrated during a private September 2013 audiogram. During the July 2014 VA examination, the auditory thresholds in the Veteran’s left and right ear did not reach any of the required frequencies to be considered hearing loss as defined in 38 C.F.R. § 3.385; nor were his speech recognition score less than 94 percent. See July 2014 VA examination. The private September 2013 audiogram reflects that the Veteran’s auditory threshold at 4000 Hertz in the left ear was 40 decibels, which meets the standard for hearing loss under VA law. 38 C.F.R. § 3.385. However, the Veteran’s auditory thresholds in his right ear did not exceed 40 decibels or more for any of the frequencies of 500, 1000, 2000, 3000, and 4000 Hertz; nor did it exceed 26 decibels for at least three of these frequencies at any time prior or during the pendency of the claim. See September 2013 audiogram. Furthermore, the September 2013 audiogram does not reflect that his speech recognition score was less than 94 percent in either ear and, notably, there is no indication that the speech recognition scores were conducted using the Maryland CNC test, as required by law. See Id. In evaluating this claim, the Board has considered the Veteran’s lay statements regarding the nature of his bilateral hearing impairment; however, a lay person is not competent to offer a diagnosis of hearing loss that meets VA’s definition. Indeed, such a diagnosis requires the administration and interpretation of audiological test results. As such is a complex medical question, the Veteran is not competent to offer a diagnosis of hearing loss. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, the Veteran is not shown to have right ear hearing loss for VA purposes prior to or during the pendency of his claim. 38 C.F.R. § 3.385. Accordingly, the preponderance of the evidence is against the grant of service connection for right ear hearing loss, as there is no evidence of a current disability. Because left ear hearing loss was shown during the appeal period, e.g., during the September 2013 audiogram, the remaining inquiry is whether there is a nexus, or link, between the Veteran’s current left hearing loss and his acknowledged noise exposure during his military service. After conducting an audiogram and reviewing the record, the July 2014 VA examiner opined that the Veteran’s current hearing loss was not likely related to his military noise exposure, as there was normal hearing on both his August 2004 entrance examination and May 2009 pre-separation examinations. In this regard, the examiner noted that, once military noise exposure is removed, hearing would not be expected to get worse. As a result, she opined that the Veteran’s current, mild, left hearing loss was not due to or aggravated by military noise exposure. In evaluating this claim, the Board places great probative weight on the opinion provided by the July 2014 VA examiner, as the opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. The Board also finds probative that there is no contrary medical opinion of record, as the audiologist who conducted the September 2013 did not provide a statement regarding the likely etiology of the Veteran’s current hearing impairment. Therefore, while the evidence of record shows that the Veteran has a current left ear hearing disability, the probative evidence of record demonstrates that such is not related to his service. Indeed, as noted, a demonstrable hearing impairment was not documented by various audiograms conducted during service and a medical professional has opined that the current left ear hearing impairment is not likely due to the Veteran’s military noise exposure. Moreover, the clinical evidence of record fails to show that left ear hearing loss manifested until 2013, more than four years after service discharge. Consequently, presumptive service connection, to include on the basis of continuity of symptomatology, for left ear hearing loss is not warranted. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. As noted, the Board has considered the statements of the Veteran and his representative linking the Veteran’s current hearing loss to his military service. However, the Veteran is not competent to attribute his hearing loss to any instance of his military service, as he has not demonstrated that he is an expert in determining the etiology of hearing loss and is a layperson in this regard. While it is in error to categorically reject layperson nexus evidence as incompetent, the Board is allowed to consider the facts of a particular case to determine the layperson’s competence. See Davidson v. Nicholson, 581 F.3d 1313 (Fed. Cir. 2009). One factor to consider is the complexity of the question to be determined. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (providing an example at footnote 4 that a layperson would be competent to diagnose a simple condition such as a broken leg but not to diagnose a form of cancer). Neither the Veteran’s nor his representative’s statements linking the Veteran’s current hearing loss to his military service are within the realm of knowledge of a layperson. Rather, such is a complex question that requires expertise. Specifically, it involves the impact of acoustic trauma and loud noises on the auditory functioning of the ear and, in this case, a medical professional has reviewed the claims file, examined the Veteran, and provided a negative nexus opinion with consideration of the impact of the Veteran’s noise exposure. Therefore, the lay statements submitted in support of this claim are outweighed by the competent, credible, and probative medical evidence of record. Accordingly, as the Veteran’s left ear hearing loss is not shown to be causally or etiologically related to any disease, injury, or incident in service and did not manifest to a compensable degree within one year of the Veteran’s discharge from service, service connection for left ear hearing loss is not warranted. In reaching this decision, the Board considered the applicability of the benefit of the doubt doctrine. However, because the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable and the Veteran’s claim is denied. 2. Entitlement to service connection for tinnitus In Charles v. Principi, 16 Vet. App. 370, 374-375 (2002), the Court specifically held that tinnitus is a condition which is capable of lay observation. See also Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran reported having tinnitus during the July 2014 VA audiological examination, as well as during the September 2019 Board hearing. This evidence sufficiently establishes the presence of the currently claimed disability, tinnitus. Accordingly, the first element of service connection is established. With respect to in-service-incurrence, the Veteran has asserted that his tinnitus began during service, and he is competent to report the events that occurred during service. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). He has provided a consistent report of the circumstances of his in-service noise exposure, as well as the onset and nature of his tinnitus specifically that his tinnitus has been present since his exposure to acoustic trauma while serving as an infantryman in a combat zone. The Board notes that the Veteran’s service personnel records reflect that his military occupational specialty (MOS) was an infantry assualtman and that his duties were performed in Iraq during the Gulf War, with ever-existing threat of rocket or ground attacks by enemy forces. The Veteran also received various military awards and decorations for his service, including the Iraq Campaign Medal. When a veteran has engaged in combat with the enemy, satisfactory lay or other evidence “shall be accepted as sufficient proof of service connection” for certain diseases or injuries, even if “there is no official record of such incurrence or aggravation in such service.” 38 U.S.C. § 1154(b). This presumption may be rebutted only by clear and convincing evidence. Id. The Board finds that the Veteran’s service records establish that he engaged in combat with the enemy and further corroborate his report of noise exposure, as his statements are consistent with the circumstances of his service. See 38 U.S.C. § 1154(a), (b). Therefore, the Board finds the Veteran’s assertions regarding his in-service noise exposure and the onset, nature, and progression of his tinnitus is competent and credible evidence sufficient to establish service incurrence of such. See 38 U.S.C. § 1154(b); Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012). However, the combat presumption does not alleviate the requirement that the evidence show a current disability attributable to the past in-service disorder. See generally Clyburn v. West, 12 Vet. App. 296, 303 (1999). Therefore, the remaining question is whether there is a nexus, or link, between the current disability and service. The Veteran presented for a VA examination in July 2014, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination. The VA examiner noted the Veteran’s report of experiencing constant, recurrent tinnitus that has been present since 2007 or 2008; however, the VA examiner noted that, since tinnitus is more likely than not found in association with hearing loss, which was not exhibited at discharge from service, it is less likely than not that the Veteran’s tinnitus was caused by or a result of his military noise exposure. The July 2014 VA examination is considered competent medical evidence. However, the Board finds that the examiner’s opinion regarding the relationship between the Veteran’s tinnitus and hearing loss does not preclude an award of benefits. As for the examiner’s nexus opinion regarding the relationship between the Veteran’s tinnitus and military noise exposure, this opinion is afforded lessened probative value because the examiner’s opinion is based on the relationship between tinnitus and hearing loss, without consideration of the Veteran’s competent and credible statements regarding the onset of tinnitus during service and continued nature since that time. Given that tinnitus is the type of condition that is capable of lay observation and the Veteran has provided competent and credible lay evidence establishing that his tinnitus began during service and has been constant since service, the Veteran’s lay statements are considered probative evidence sufficient to support the grant of service connection. Indeed, the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Under these circumstances, the Board finds that the lay and medical evidence is at least in relative equipoise with respect to the issue of whether the Veteran’s tinnitus was incurred during service as a result of his military noise exposure. Therefore, entitlement to service connection for tinnitus is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for a left ankle disability 4. Entitlement to service connection for a low back disability As noted, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be established for a Persian Gulf veteran who exhibits objective indications of a qualifying chronic disability resulting from undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and cannot be attributed to any known clinical diagnosis by history, physical examination, or laboratory tests. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on qualifying chronic disability, unlike those for “direct service connection,” there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). Notably, laypersons are competent to report objective signs of illness. A qualifying chronic disability for VA purposes is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or functional gastrointestinal disorders) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that VA determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; and (12) abnormal weight loss. 38 C.F.R. § 3.317(b). If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. The Veteran seeks service connection for disabilities affecting his left ankle and low back. For the reasons stated below, the Board finds that service connection is not warranted. The Veteran’s STRs do not contain any complaints, treatment, or diagnoses related to a left ankle or low back disability. During his June 2009 pre-separation examination, the Veteran reported that he rolled his ankle during hikes on a couple of times and, in this regard, previous STRs show the Veteran was diagnosed with a varus sprain in his right ankle after seeking treatment for right ankle pain. The Veteran did not report having left ankle pain at that time or any other time during service. He also denied having back pain on various occasions during service, including during post-deployment health assessments in March 2007 and July 2008 and during his June 2009 pre-separation examination. Post-service treatment records show that the Veteran reported having joint pain, including in his ankles, and he reported that both ankles were treated during service. Notably, the Veteran never specifically endorsed having left ankle pain and x-rays of his ankles were negative. See e.g., VA treatment records dated April and December 2013. Similarly, the post-service treatment records note the Veteran experienced back pain, but clinicians noted that the Veteran was not wearing his back brace, which he was given for a clavicle facture, because he stated that the brace hurt his back. See July 2019 VA treatment record. The post-service treatment records do not contain any specific complaints of low back pain or problems or a diagnosis of a lumbar spine or low back disability. The Veteran was afforded VA examinations in July 2014. During the ankle examination, the Veteran denied having any symptoms or problems with the left ankle and only reported having sharp pain in his right ankle. Physical examination and x-rays of the left ankle were normal. During the back examination, he reported having pain in the right trapezium, which the Board notes involves the upper back and shoulder area, as opposed to the lower back area. The Veteran attributed his trapezium pain to carrying weight on his back during marches and hikes during service in Iraq, but he stated the pain was episodic in nature, as it had only occurred three times since service, in 2010, 2012 and the summer of 2013. Physical examination and x-rays of the thoracolumbar spine were normal, with the exception of a slight thoracic curvature. Accordingly, the VA examiner did not render a diagnosis related to the thoracolumbar spine, as he noted the examination was normal. See July 2014 VA examinations. Given the above, service connection is not warranted. The Veteran is considered to be a Persian Gulf War Veteran, as his service personnel records show that he served in Iraq and received the Iraq Campaign Medal. The Board notes the Veteran does not have a clinical diagnosis for his left ankle or low back symptoms; however, service connection under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 for a qualifying chronic disability based on Persian Gulf War service is not warranted. As noted, service connection based on Persian Gulf War service requires a Persian Gulf veteran exhibit objective indications of a chronic disability that is perceptible to an examining physician. The July 2014 VA examiner essentially concluded there are no signs of a chronic disability involving the left ankle and low back. As noted, the Veteran denied having any left ankle pain or problems during the examination and he reported having trapezium pain, as opposed to any low back pain or problems. The VA examiner found normal left ankle and thoracolumbar muscle strength and range of motion, and the examination was deemed completely normal. In evaluating this claim, the Board finds significant that the Veteran has not explicitly reported having pain or other symptoms in his left ankle or low back. He specifically denied having left ankle pain during the VA examination and is not shown to have sought treatment for left ankle pain since service. Similarly, the Veteran did not endorse having any low back pain during the VA examination or in any other clinical setting but has, instead, reported having trapezium pain. The Board acknowledges that, during the September 2019 hearing, the Veteran reported having the same ankle symptoms since service but, as noted, he is shown to have only complained of right ankle pain during service. Parenthetically, the Board notes that service connection has been established for the Veteran’s right ankle disability. During the hearing, he also testified that he complained of low back problems during service and continues to have low back issues, but these statements are not supported by the other evidence of record. Therefore, after considering the lay and medical evidence of record, the Board finds the Veteran has not provided any credible lay statements or evidence describing signs or symptoms of a qualifying chronic left ankle or low back disability. To the extent that the Veteran’s testimony regarding his ankle and back symptoms can be deemed credible lay evidence of objective indicators of a chronic left ankle and low back disability, the Board notes that the evidence does not reflect that his symptoms have manifested to a compensable degree during the appeal, when comparing the evidence to the diagnostic code for evaluating left ankle or spinal disabilities. As noted, the evidence shows the Veteran has demonstrated normal muscle strength and range of motion in his left ankle and thoracolumbar spine, and there is no evidence showing that his left ankle or low back pain is disabling to the extent that it has resulted in a functional impairment in earning capacity. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, 5270-5274; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). For these reasons, service connection based on the presumption concerning undiagnosed illnesses is not warranted in this case. Turning to direct service connection, the Board finds that service connection on a direct basis for the claimed left ankle and low back disabilities is not warranted. 38 C.F.R. § 3.303. The competent evidence of record shows the Veteran does not have a current diagnosis of a left ankle or low back disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). As also noted, the Veteran has not provided any competent lay evidence or statements establishing that he has left ankle or low back symptoms, such as pain, that results in functional impairment that affects his earning capacity. In the absence of a current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Therefore, the Veteran’s claims are denied, and the benefit of the doubt doctrine is not applicable. REASONS FOR REMAND 1. Entitlement to service connection for a gastrointestinal disability, claimed as irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD), is remanded. The Veteran has asserted that his current gastrointestinal problems, which he claimed as IBS and GERD, are a result of his exposure to water and other contaminates during his service in Southwest Asia. The Veteran testified that he drank unfiltered water while stationed in Iraq and experienced diarrhea during service. He also testified that his stomach has not been the same since service. In July 2014, a VA examiner noted the Veteran’s reported symptoms of heartburn and nausea after eating and stated that his symptoms were consistent with GERD. The examiner noted that the Veteran has never been diagnosed with IBS but, instead, was diagnosed with GERD in December 2013. The examiner ultimately opined that the Veteran’s GERD was less likely incurred in service because there was no evidence of complaints, treatment, or diagnosis of such in service. While the VA examiner noted that GERD was diagnosed in December 2013, this statement is not supported by the medical evidence of record, as a diagnosis of GERD is not reflected in the treatment records associated with the claims file. The evidence shows that the Veteran did, in fact, report feeling nauseated after eating in December 2013; however, the diagnosis was “h pylori” and subsequent treatment records reflect that “helicobacter pylori gastrointestinal tract infection” is listed on the Veteran’s active problem list. See e.g., December 2013 VA treatment record; July 2019 VA treatment record. Because the VA examiner inaccurately reported that the Veteran had been diagnosed with GERD, the Board finds there remains a question as to whether the Veteran’s gastrointestinal complaints are, in fact, attributable to GERD, IBS, or any other disease with a clear and specific etiology. There is also a question as to whether the Veteran’s gastrointestinal complaints represent an undiagnosed illness, a functional gastrointestinal disorder, which would qualify as a diagnosable but medically unexplained chronic multi-symptom illness (MUCMI), or a diagnosable chronic multi-symptom illness with partially explained etiology. Therefore, a remand is needed to obtain an addendum opinion. 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for a right knee disability is remanded. The evidentiary record contains two medical opinions which state that the Veteran’s claimed bilateral knee disabilities are less likely than not incurred in or caused by an in-service event or injury. In July 2014, the VA examiner noted that, while the Veteran reported having knee pain at separation and in January 2014, x-rays of his knees were normal in January 2014 and examination of his knees at that time was also normal. See July 2014 VA examination. In October 2016, the VA examiner incorrectly noted that the Veteran’s service records were silent for knee injuries or problems and that VA treatment records noted only arthralgias in the knees and contained normal x-rays of his knees. See October 2016 VA examination report. Since those opinions were obtained, both private and VA treatment records have revealed medial meniscus tears in both the left and right knee. See August 2019 VA treatment record; October 2019 private treatment record. Because the negative nexus opinions are based, at least partially, on the lack of evidence showing a disability shown on x-ray or other imaging, the Board finds an addendum opinion is needed. 4. Entitlement to service connection for a deviated nasal septum During the September 2019 hearing, the Veteran testified that his nose was broken during active duty service and that, as a result of the injury, he continues to have a deviated septum, breathing problems, and chronic upper respiratory infections. The Veteran was afforded a VA examination in July 2014, during which the examiner noted that post-service records dated in March 2014 show the Veteran was diagnosed with a nasal bone fracture, deviated septum, hypertrophy nasal turbinates and nasal cavity/sinus otherwise unspecified. The examiner noted that the Veteran was prescribed medication and that a CT scan was ordered but no results were available. The Board’s review of the claims file has not revealed any private treatment records dated in March 2014 which contain a diagnosis of a nasal bone fracture, deviated septum, or hypertrophy of the nasal turbinates. While the Board accepts the examiner’s report of such diagnoses, any evidence considered by the VA examiner should be associated with the claims file. Additionally, the examiner opined that the post-service diagnoses are less likely than not incurred during service, at least partially on the basis that a septal deviation was not evident on physical examination. In this regard, the Board notes that the results of the CT scan noted in the March 2014 private treatment records may reveal a septal deviation or other findings suggestive that the post-service diagnoses are likely related to the in-service. Therefore, a remand is needed to obtain the private treatment records cited in the July 2014 examination report and, if deemed necessary, to obtain an addendum opinion. The matters are REMANDED for the following action: 1. A after obtaining any necessary authorization from the Veteran, obtain any outstanding private treatment records from South Texas Sinus Institute, including records dated from March 2014 to the present. All attempts to secure these records, and any response received, should be documented in the claims file, following the procedures set forth in 38 C.F.R. § 3.159. 2. Obtain an addendum opinion regarding the Veteran’s gastrointestinal disability. Following a review of the record, the examiner is asked to address the following: Are there objective indications that the Veteran is suffering from chronic gastrointestinal disability? If so, the examiner must determine whether these symptoms can be attributed to any known clinical diagnosis, such as GERD. If the Veteran has any symptomatology that is not attributable to a known clinical diagnosis, the examiner should opine whether it is as likely as not (50 percent or more probability) that the symptoms are due to an undiagnosed illness OR medically unexplained chronic multi-symptom illness, such as IBS or any other functional gastrointestinal disorder (a condition marked by chronic or recurrent symptoms related to any part of the gastrointestinal tract), resulting from service in Southwest Asia during the Gulf War. With respect to any currently diagnosed gastrointestinal disability, the examiner should state whether it is at least as likely as not (50 percent or more probability) that the disability had its onset during or is otherwise related to the Veteran’s military service, to include any exposures during his service in Southwest Asia. A complete rationale must be provided for any opinion offered. The examiner must consider and address all lay and medical evidence of record with respect to the onset and progression of the Veteran’s gastrointestinal symptoms. 3. Obtain an addendum opinion regarding the Veteran’s left and right knee disabilities. Following a review of the complete record, the examiner is asked to address the following: Identify all left and right knee disabilities diagnosed during the appeal period, i.e., since April 2013. For each identified condition, the examiner should state whether it is at least as likely as not (50 percent or more probability) that the knee disability had its onset during or is otherwise related to the Veteran’s military service, to include the pain reported at separation from service. A complete rationale must be provided for any opinion offered. The examiner must consider and address all lay and medical evidence of record with respect to the onset and progression of the Veteran’s knee pain and problems. (Continued on the next page)   4. Readjudicate the claims on appeal with consideration of all evidence associated with the claims file since the issuance of the June 2019 supplemental statement of the case. M. Donohue Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Turnipseed, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.