Citation Nr: 20011992 Decision Date: 02/13/20 Archive Date: 02/12/20 DOCKET NO. 19-23 424 DATE: February 13, 2020 ORDER Entitlement to an initial disability rating in excess of 10 percent for hammer toe of the right foot great toe (claimed as right foot big toe deformation) is denied. Entitlement to an initial compensable disability rating for furunculitis of the groin (to include penile lesions) (claimed as penis sores, irritability, groin and crotch sores, rash, and pain) is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD), anger disorder, anxiety disorder, and depressive disorder (claimed as depression), is denied. Entitlement to service connection for bilateral leg cramp condition is denied. REMANDED Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for upper respiratory condition, also claimed as allergies, is remanded. Entitlement to service connection for hypertension (claimed as high blood pressure) is remanded. Entitlement to service connection for acid reflux condition (to include esophagus inflammation) is remanded. Entitlement to service connection for type II diabetes mellitus is remanded. Entitlement to service connection for hemorrhoids is remanded. Entitlement to service connection for irritable bowel syndrome is remanded. Entitlement to service connection for prostate cancer, to include residuals of prostate cancer, is denied. FINDINGS OF FACT 1. The Veteran’s hammer toe of the right foot great toe (claimed as right foot big toe deformation) is rated as 10 percent disabling, which is the maximum schedular rating permitted for hammer toe. 2. The Veteran’s furunculosis of groin is manifested by infrequent penile lesions (2 or 3 times per year), frequent crotch irritation (several times per month) treated with over-the-counter medicated powder. 3. The preponderance of the evidence of record is against finding that the Veteran has had an acquired psychiatric disability at any time during or approximate to the pendency of the claim. 4. The preponderance of the evidence of record is against finding that the Veteran has had bilateral leg cramps at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for hammer toe of the right foot great toe (claimed as right foot big toe deformation) have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.59, 4.71a, Diagnostic Code 5282. 2. The criteria for a compensable disability rating for furunculitis of the groin (to include penile lesions) (claimed as penis sores, irritability, groin and crotch sores, rash, and pain), have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7806, Diagnostic Code 7820. 3. The criteria for service connection for an acquired psychiatric disability, to include PTSD, anger disorder, anxiety disorder, and depressive disorder (claimed as depression) are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for bilateral leg cramp condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Marine Corps from September 1958 until his honorable discharge in September 1962. During his service, the Veteran was stationed at Camp Lejeune, North Carolina from January 7, 1959, with brief deployments to Fleet Marine Force Atlantic noted that may have taken him from Camp Lejeune, North Carolina, intermittently until September 29, 1962. However, the Board notes that the Veteran clearly has well over 30 days (cumulative and consecutive) of service at Camp Lejeune, North Carolina. These matters come before the Board of Veterans’ Appeals (Board) on appeal from June 2017 and May 2019 rating decisions by the Philadelphia, Pennsylvania Regional Office (RO) of the United States Department of Veterans Affairs (VA). This appeal has been advanced on the Board’s docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). 1. Entitlement to an initial disability rating in excess of 10 percent for hammer toe of the right foot great toe (claimed as right foot big toe deformation) Although the Veteran does not provide a basis for the contention, he contends that he is entitled to a higher rating. As a preliminary matter, the Board notes that the Veteran’s assertion, and the evidence of record demonstrates that the Veteran’s disability is limited to hammer toe of the right great toe and not multiple toes of the right foot. Therefore, the Board has recharacterized the claimed disability to hammer toe of the right foot great toe (claimed as right foot big toe deformation). The Veteran’s hammer toe of the right foot great toe (claimed as right foot big toe deformation) is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5282, for hammer toe. Under Diagnostic Code 5282, a noncompensable rating is warranted for hammer toes of single toes. A maximum 10 percent rating is warranted for hammer toe of all toes, unilateral, without claw foot. 38 C.F.R. § 4.71a, Diagnostic Code 5282. The Board notes that the May 2019 rating decision increased the Veteran’s disability rating, effective January 7, 2016, the initial grant of service connection, from a non-compensable to a 10 percent disability rating due to painful great toe of the right foot. As the Veteran is in receipt of the highest schedular rating for hammer toe, there is no basis to award a higher rating. The Board has also considered the other Diagnostic Codes pertaining to the foot. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). In Scott v. Wilkie, the Federal Circuit expressly adopted the Court’s holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court’s holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous Diagnostic Codes, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight conditions listed in the rating schedule. Id. Here, the Veteran’s disability is specifically listed under the rating schedule and therefore cannot be rated under a different Diagnostic Code. Additionally, the evidence of record does not reflect that the Veteran has any other service-connected foot disabilities that would warrant a separate rating under a different Diagnostic Code. Although the Veteran claims and evidence shows that the Veteran has hammer toe of the right great toe (a single toe), which would be rated as a non-compensable disability rating, he is rated at the maximum 10 percent rating, which is warranted for hammer toe of all toes, unilateral, without claw foot. As the Veteran already has the maximum schedular disability rating the appeal is denied. 2. Entitlement to an initial compensable disability rating for furunculitis of groin Although the Veteran does not provide a basis for the contention, he contends that he is entitled to a higher rating. The Veteran’s furunculitis of the groin (to include penile lesions) (claimed as penis sores, irritability, groin and crotch sores, rash, and pain) is rated under Diagnostic Code 7820-7806. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran’s skin condition; and (2) whether the given treatment is “like” a corticosteroid or other immunosuppressive drug.” Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. Here, the evidence of record demonstrates that the predominant disability is furunculitis of the groin. As noted in an August 2016 VA examination, the Veteran’s furunculosis of groin is manifested by infrequent penile lesions (2 or 3 times per year), frequent crotch irritation (several times per month), and is treated with over-the-counter medicated powder. The VA examiner noted that the Veteran had a moist rash in the inguinal folds, but no penile or scrotal lesions. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the pre-August 13, 2018, regulations because the Veteran’s furunculitis of the groin does not more nearly approximate at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the August 13, 2018, regulations because the Veteran’s furunculitis of the groin does not more nearly approximate characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12- month period. The Board acknowledges that the Veteran believes that the disability on appeal merits a higher disability rating. However, he does not assert, and medical treatment records including an August 2016 VA examination do not show that the Veteran’s disability more nearly approximates the criteria in the next higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a compensable rating for furunculitis of the groin. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection for certain chronic diseases, including diabetes mellitus, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), that is, a diagnosis that conforms to the Diagnostic and Statistical Manual of Mental Disorders (DSM 5); a link, established by the medical evidence, between current symptoms and a stressor in service; and credible supporting evidence that the claimed stressor in service occurred. 38 C.F.R. § 3.304(f). If a stressor that is claimed by a Veteran is related to the Veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a physician or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of posttraumatic stress disorder and that the Veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3). “Fear of hostile military or terrorist activities” means that a Veteran experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of the Veteran or others, and the Veteran’s response to the event or circumstances involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f)(3). Service connection for disabilities due to service at Camp Lejeune between August 1, 1953, through December 31, 1987, and the subsequent development of the following disabilities: kidney cancer, liver cancer, non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. Service at Camp Lejeune for Veteran’s, Reservists, and former National Guard members must have been for at least 30 days (cumulative) during the specified time frame. A presumption of service connection based on exposure to contaminants in the water supply at Camp Lejeune is not warranted for any other disability. Service connection may also be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of the disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service condition, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. 3. Entitlement to service connection for an acquired psychiatric disability, to include PTSD, anger disorder, anxiety disorder, and depressive disorder The Veteran asserts that his acquired psychiatric disabilities are related to his service at Camp Lejeune, North Carolina. As a preliminary matter, the Board is obligated to construe a claim for a psychiatric disorder liberally to include all psychiatric disorders found. Clemons v. Shinseki, 23 Vet. App. 1 (2009) (scope of mental health disability claim includes any mental disability that may reasonably be encompassed by claimant’s description of the claim, symptoms, and other information of record). Therefore, the Board has considered the four separate claims of entitlement to service connection for PTSD, entitlement to service connection for anxiety disorder, entitlement to service connection for anger disorder, and entitlement to service connection for depressive disorder (claimed as depression) as a single claim for entitlement to service connection for an acquired psychiatric disability, to include PTSD, anger disorder, anxiety disorder, and depressive disorder (claimed as depression). The Board finds that the Veteran has not been diagnosed with any psychiatric disorder. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). Neither the Veteran’s VA treatment records, dated from September 2005 to April 2019, nor private treatment records reflect a diagnosis of an acquired psychiatric disability. In the absence of a disability during the pendency of the claim, service connection cannot be established. See Brammer v. Derwinski, 2 Vet. App. 223 (1992). There is also insufficient evidence of a disability at any point during the claim period or shortly before. See McClain v. Nicholson, 21 Vet. App. 219 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Accordingly, entitlement to service connection is denied. At the core of service connection is functional impairment, which can be a disability even if there is no underlying diagnosis. Consideration should be given to the impact of functional limitation. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Here there is no assertion of functional limitation due to entitlement to service connection for an acquired psychiatric disability, to include PTSD, anger disorder, anxiety disorder, and depressive disorder (claimed as depression). In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for bilateral leg cramp condition The Veteran asserts that he is entitled to service connection for bilateral leg cramps. First, the Board finds that there is not a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). VA treatment records dated from September 2005 to April 2019, and private treatment records dated from 2012 to 2019 do not reflect a diagnosis of leg cramps in either leg. In the absence of a disability during the pendency of the claim, service connection cannot be established. See Brammer v. Derwinski, 2 Vet. App. 223 (1992). There is also insufficient evidence of a disability at any point during the claim period or shortly before. See McClain v. Nicholson, 21 Vet. App. 219 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Accordingly, entitlement to service connection is denied. At the core of service connection is functional impairment, which can be a disability even if there is no underlying diagnosis. Consideration should be given to the impact of functional limitation. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Here there is no assertion of functional limitation due to residuals of leg cramps. Accordingly, entitlement to service connection for prostate cancer is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for sleep apnea is remanded. 2. Entitlement to service connection for erectile dysfunction is remanded. 3. Entitlement to service connection for upper respiratory condition, also claimed as allergies, is remanded. 4. Entitlement to service connection for hypertension (claimed as high blood pressure) is remanded. 5. Entitlement to service connection for acid reflux condition (to include esophagus inflammation) is remanded. 6. Entitlement to service connection for type II diabetes mellitus is remanded. 7. Entitlement to service connection for hemorrhoids is remanded. 8. Entitlement to service connection for prostate cancer is remanded. The Veteran asserts that the above disabilities are due to his contaminated water exposure during his service at Camp Lejeune, North Carolina. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA’s duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The RO did not provide the Veteran with an examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, the Veteran has been diagnosed with sleep apnea, erectile dysfunction, upper respiratory condition, hypertension, acid reflux condition, type II diabetes mellitus, hemorrhoids, and prostate cancer (the Board notes that prostate cancer was originally diagnosed in 2007, with a recurrence noted in January 2019). Moreover, the Veteran was exposed to contaminated water while he served at Camp Lejeune, North Carolina. The Board acknowledges that these diagnoses are not on the list of disabilities associated with exposure to contaminated water at Camp Lejeune; nonetheless direct service connection may still be established. Regardless of the applicability of the presumptive association to water exposure, a claimant is not precluded from establishing service connection with proof of direct causation. As such, remand is necessary to obtain medical opinions on the issue of service connection for these claimed disabilities. 9. Entitlement to service connection for irritable bowel syndrome is remanded. The Veteran was afforded a VA examination in September 2016 concerning his irritable bowel syndrome. The September 2016 VA examiner opined that the Veteran’s irritable bowel syndrome is less likely than not (less than 50 percent probability) incurred in or caused by his illness during service. However, the September 2016 VA examiner did not opine on the theory that his irritable bowel syndrome is due to contaminated water exposure at Camp Lejeune, North Carolina. Therefore, the September 2016 VA examination is inadequate. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matters are REMANDED for the following actions: 1. Schedule the Veteran for VA examinations by appropriate clinicians to address the nature and etiology of the claimed sleep apnea, erectile dysfunction, upper respiratory condition, hypertension, acid reflux condition, diabetes mellitus type II, hemorrhoids, and prostate cancer. The entire claims file must be made available to and be reviewed by the examiner(s) in conjunction with the examinations. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. For each diagnosis, to include sleep apnea, erectile dysfunction, upper respiratory condition, hypertension, acid reflux condition, diabetes mellitus type II, hemorrhoids, and/or prostate cancer, the examiner is requested to provide an opinion as to whether it is at least as likely as not (a 50 percent probability or more) that the disability began in service, was caused by service, or is otherwise related to active military service, including but not limited to contaminated water exposure while he was stationed at Camp Lejeune, North Carolina. A complete rationale must be provided for any opinion offered. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. 2. Contact the VA examiner who provided the August 2016 VA medical opinion (or if he or she is no longer available, a suitable replacement) on the etiology of the claimed irritable bowel syndrome and ask the examiner to review the record and prepare an addendum to the medical opinion. The examiner is requested to provide an opinion as to whether it is at least as likely as not (a 50 percent probability or more) that the Veteran’s disability began in service, was caused by service, or is otherwise related to active military service, including but not limited to contaminated water exposure while he was stationed at Camp Lejeune, North Carolina. A complete rationale must be provided for any opinion offered. If any requested medical opinion cannot be given, the examiner should state the reason(s) why. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the AOJ should schedule the Veteran for such an examination. N. NELSON Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Deemer, Associate 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.