Citation Nr: 20021261 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 14-06 201 DATE: March 25, 2020 ORDER Service connection for osteoarthritis, right hand, is granted. REMANDED Entitlement to service connection for a skin disability, to include tinea cruris, is remanded. Entitlement to service connection for left hand disability is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for right ear hearing loss, to include as secondary to service-connected left ear hearing loss, is remanded. REFERRED In its December 2018 decision and remand, the Board referred the issues of entitlement to service connection for left knee disability and tinnitus for adjudication by the Agency of Original Jurisdiction (AOJ). As no action has been taken, the Board refers them again for appropriate action. 38 C.F.R. § 20.904(b). FINDING OF FACT The Veteran’s osteoarthritis, right hand, began during active duty service and continued thereafter. CONCLUSION OF LAW The criteria for service connection for osteoarthritis, right hand, are met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1154(b), 5107(b); 38 C.F.R. §§ 3.102, 3.303(a)–(b), (d), 3.307, 3.309(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1972 to May 1996. These matters come before the Board of Veterans’ Appeals (Board) on appeal from June 2012 and July 2019 rating decisions. In April 2017, the Veteran testified at a videoconference Board hearing before the undersigned, and a transcript is of record. In December 2017, the Board remanded these issues for further development, and the case has been returned for appellate consideration. The Board finds there has been substantial compliance with its December 2017 remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial and not strict compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)); see also Dyment v. West, 13 Vet. App. 141, 146–47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board’s remand). In a July 2019 rating decision, the Regional Office (RO) granted service connection for: hearing loss, left ear, assigning a noncompensable disability evaluation effective March 31, 2004; and scar, residual, s/p left great toe laceration (claimed as left foot injury), assigning a noncompensable disability evaluation effective March 31, 2004. As this represents full grants of the benefits sought, those issues are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (noting that a grant of service connection extinguishes appeals before the Board). Furthermore, the Veteran has not expressed disagreement with either the disability evaluation or effective date assigned. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In a July 2019 supplemental statement of the case, the RO denied service connection for disabilities of the skin, right ear hearing loss, back, and bilateral hands, so these issues remain on appeal. Duties to Notify and Assist In the Veteran’s representative’s January 2020 appellate brief, a challenge to each June 2018 VA examiners’ qualifications was raised by naming each examiner, their professional designation, and the nature of the examination undertaken by each. At issue are the physician assistant, who performed the VA examinations for skin conditions and fibromyalgia, and the nurse practitioner, who performed the VA examinations for conditions of the foot, back, and hand and finger. It was contended that neither of these non-physician examiners were “shown to have any particular expertise, experience, training, or competence in commenting on Orthopedic or Dermatologic disorders.” It was argued: “Absence of competence renders their conclusions no more probative than the appellant’s lay assertions that there is nexus between his claimed conditions and active military service.” Competency of the examiner and adequacy of an examination are two separate inquires. Mathis v. McDonald, 834 F.3d 1347, 1351 (Fed. Cir. 2016) (Hughes, J., concurring in denial of rehearing en banc). Statute and implementing regulations require that VA medical examinations and opinions be based on competent medical evidence, defined, in relevant part, as “‘evidence provided by a person who is qualified through education, training, or experience, to offer medical diagnoses, statements, or opinions.’” Francway v. Wilkie, 940 F.3d 1304, 1307 (Fed. Cir. 2019) (en banc), petition for cert. filed, No. 19-604, Nov. 7, 2019 (quoting 38 C.F.R. § 3.159(a)(1)); see also 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). There is a presumption that a VA examiner is competent, which is referred to as the presumption of competency, but there is no requirement that a VA examiner is the most highly qualified in a medical discipline. See Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009). Here, a physician assistant and a nurse practitioner performed the Veteran’s VA examinations in June 2018 for conditions of the skin, foot, back, hand and finger, and fibromyalgia. The Board notes that the nurse practitioner’s examination reports were countersigned by a physician. These examiners are specially trained general medical professionals who are tested as to their general knowledge and competency within the scope of their training prior to being licensed to practice. As such, they are presumed to be competent, and their opinions are not on a par with a lay contention. See 38 C.F.R. § 3.159(a)(1), (2) (defining competent medical and lay evidence). There is no requirement that a medical examination be conducted by a physician or that any examiner have specialty training related to the nature of the examination being undertaken. Cox v. Nicholson, 20 Vet. App. 563, 568 (2007) (citing Goss v. Brown, 9 Vet. App. 109, 114 (1996)). For the presumption of competence to be rebutted, the Veteran must raise the issue of examiner competence in the first instance by something more than a general assertion that an examination or opinion is inadequate. Francway, 940 F.3d at 1308. [O]nce the veteran raises a challenge to the competency of the medical examiner, the presumption has no further effect, and, just as in typical litigation, the side presenting the expert (here the VA) must satisfy its burden of persuasion as to the examiner’s qualifications. The Board must then make factual findings regarding the qualifications and provide reasons and bases for concluding whether or not the medical examiner was competent to provide the opinion. 38 U.S.C. § 7104(d). Since the veteran is obligated to raise the issue in the first instance, the veteran must have the ability to secure from the VA the information necessary to raise the competency challenge. Once the request is made for information as to the competency of the examiner, the veteran has the right, absent unusual circumstances, to the curriculum vitae and other information about the qualifications of a medical examiner. This is mandated by the VA’s duty to assist. See 38 U.S.C. § 5103A; Harris v. Shinseki, 704 F.3d 946, 948 (Fed. Cir. 2013) (collecting cases). Id. Here, the Veteran has not requested the curriculum vitae or any other information concerning the individual qualifications of the physician assistant and the nurse practitioner who performed his June 2018 VA examinations. He has not asserted any unusual facts of his claimed disabilities that would require the heightened education and experience of a physician or specialist. Rather, the assertion made is that physician assistants and nurse practitioners as groups of medical professionals are not competent to perform these examinations. As this is a general challenge, the Board finds that the presumption of competence as to the physician assistant and nurse practitioner here has not been rebutted, and consequently, the Board finds the physician assistant and nurse practitioner who performed the Veteran’s June 2018 VA examinations to have been competent to perform those examinations. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110,1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). For certain enumerated chronic diseases, such as arthritis, service connection may be granted based upon a presumption of incurrence in or aggravation by service despite the lack of evidence of such disease during service if diagnosed and manifested to a compensable degree within a prescribed period, generally one year, after separation from qualifying service. 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); see Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); see also Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013) (constraining § 3.303(b) to those chronic diseases listed in § 3.309(a)). Additionally, for those same enumerated chronic diseases service connection may be granted despite the lack of evidence of such disease during service if there is a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” 38 C.F.R. § 3.303(b), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. 38 C.F.R. § 3.307(b). The Veteran’s military personnel records show that he had multiple deployments to Saudi Arabia during 1992 and 1993 such that he is considered a Persian Gulf veteran for the purpose of compensation for certain disabilities occurring in Persian Gulf veterans. 38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317. The claimant bears the burden of presenting and supporting a claim for benefits. 38 U.S.C. § 5107(a); Fagan v. Shinseki, 573 F.3d 1282, 1286–88 (Fed. Cir. 2009). In making determinations, VA is responsible for ascertaining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Here, the Board reviewed all evidence in the claims file, with an emphasis on that which is relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380–81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claims. 1. Entitlement to service connection for right hand disability. In his March 2004 claim, the Veteran sought service connection for “knuckles pain in joints,” which has been construed as a claim for service connection for right and left hand disabilities. The question for the Board, therefore, is whether the Veteran has a current disability that began during service or is at least as likely as not related to service, including as a chronic disease that was noted as chronic in service or that manifested to a compensable degree in service or within the applicable presumptive period, or whether continuity of symptomatology has existed since service. Resolving reasonable doubt in favor of the Veteran, the Board concludes that the Veteran has a current diagnosis of osteoarthritis, right hand, that began during active duty service and continued thereafter. 38 U.S.C. §§ 1110, 1112, 1113, 1154(b), 5107(b); 38 C.F.R. §§ 3.303, 3.307, 3.309(a); Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Private medical records from Dr. O.E.A. show that the Veteran was seen in February 2014 for bilateral hand pain, during which the Veteran reported the single occurrence of bilateral hand pain that was of several years duration. It was noted as not being a recurrent problem, rather being one episode or occurrence, characterized by constant upper extremity pain. No details were provided as to the setting in which the symptoms first occurred. It was noted that previous X-rays had been taken of the hands at Moody Air Force Base, which revealed arthritic changes of the PIP joint of the middle finger of the right hand. All the other joints showed no significant arthritic changes. The Veteran was advised that his symptoms were caused by osteoarthritis. Osteoarthritis and allied disorders of osteoarthritis, localized, of the dominant hand, which was the right, was diagnosed. During a follow up examination in November 2014, the Veteran was referred to a rheumatologist for his bilateral hand pain. Consequently, the Board finds that the Veteran has a current right-hand disability of osteoarthritis. The Veteran’s service treatment records show that in January 1995 the Veteran was seen for soreness stiffness in PIPs, MCPs of hands of some days’ duration. It was noted minimal tender PIPs, MCPs both hands, and there was good range of motion. The diagnosis was probable degenerative joint disease and Naprosyn was prescribed. On his March 1996 report of medical history for retirement, the Veteran indicated Yes to the following three questions: (1) swollen or painful joints, (2) arthritis, rheumatism, or bursitis, and (3) bone, joint, or other deformity. The medical officer documented: “Patient states finger deformity of 3rd, 4th, and 5th digits of right hand, no fractures, no known cause, childhood, mild, NCNS. Swollen and painful joint, self diagnosed arthritis, right hand, first noted Jan 1995, treated with Naprosyn with poor results, member currently self treating with Tylenol with good results, no known cause, ongoing condition.” The Veteran is competent to report his symptoms, and the Board finds his reports of ongoing right-hand symptoms of arthritis credible because they have been consistent and supported by the medical evidence. See 38 C.F.R. § 3.159(a)(1)–(2) (defining competent medical evidence and competent lay evidence); Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469–70 (1994) (noting that competent lay evidence requires facts perceived through the use of the five senses); Caluza v. Brown, 7 Vet. App. 498, 511 (1995). As the Veteran’s lay evidence is competent and credible, the Board assigns it high probative value. This being the case, the evidence establishes that, during service, the Veteran was treated for right-hand symptoms that were medically identified as probably due to arthritis. Those symptoms persisted throughout the rest of the Veteran’s service and were medically recognized as an “ongoing condition” at the time of separation. The medical officer performing the separation examination did not challenge the Veteran’s report of a diagnosis of arthritis of the right hand. Consequently, the Board finds that the Veteran’s right-hand disability initially manifested during active duty service. While the Veteran is entirely competent to report his symptoms, he is not competent to proffer an opinion as to causal relationship to service. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (stating that “lay persons are not competent to opine on medical etiology or render medical opinions.”). Such opinions require specific medical training and are beyond the competency of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1376–77 (Fed. Cir. 2007); see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995); Prejean v. West, 13 Vet. App. 444, 448–9 (2000). During his April 2017 hearing, the Veteran stated that while stationed in Korea he had pains in his joints, including ankles, knees, and his fingers, but the only joints that kept swelling were his fingers. He stated that when he went for treatment, it was written up as just his fingers, but he actually had pain in his joints. He stated that he was told he had arthritis, and another name for it, that there was nothing they could do, and he was prescribed pain medication. He stated “that’s what’s been going on since the 70’s.” He stated that prior to taking medication, the pain had been constant since service. He stated that the week before the hearing a ring had to be cut off because his fingers had gotten big; he was told this was due to osteoarthritis. In June 2018, the Veteran was afforded a VA examination for hand and finger conditions, during which right-hand osteoarthritis was diagnosed. The Veteran reported that while stationed in Korea the cold started bothering his right hand. He reported being seen by doctors who told him that it was arthritis and that there was nothing to be done. He reported currently having constant pain in all PIP and MCP joints of the right hand, and cold weather continued to aggravate it. It was indicated that the Veteran’s dominant hand was the right. Range of motion testing revealed abnormal range on the right hand and enlarged PIP joints right index and long fingers were noted. It was indicated that X-rays documented the presence of degenerative or traumatic arthritis of the right hand. The examiner opined that the Veteran’s right-hand disability was not due to, caused by, or aggravated by service. It was noted that there was no imaging evidence obtained during service of the presence of arthritis, and there was no “mention of joint enlargement.” It was stated that the March 1996 report of medical examination for retirement showed normal examination of bilateral upper extremities. It was stated: “The veteran’s bilateral hand pain had resolved by the time of separation.” It was noted that the available medical records within two years of discharge were silent for hand complaint such that the “bilateral hand symptoms complained of 20+ years later cannot reasonably be connected to AD service when there are multiple other aging/occupational/daily activity factors in the intervening years.” It was stated that history of intercurrent injury was unknown and that there was “no objective evidence of any continuity of the symptoms since service or otherwise providing a nexus between the veteran’s currently reported symptoms and service.” As factfinder, the Board has the responsibility to determine the credibility and weight to be given to the evidence. See Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300–04 (2008); Prejean v. West, 13 Vet. App. 444, 448–49 (2000) (stating that factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Here, the Board finds the June 2018 VA examiner’s medical opinion problematic because it failed to account for the full medical record in the Veteran’s service treatment records as it pertained to his right hand, and the examiner failed to consider the lay and medical evidence establishing continuity of symptomatology of the Veteran’s right-hand disability. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based upon an inaccurate or incomplete factual premise is not probative). The examiner’s statement that the Veteran’s symptoms were resolved at the time of retirement from service is contradicted by the Veteran’s medical reports at the time of separation. Furthermore, the examiner stated that there were “multiple other aging/occupational/daily activity factors in the intervening years” without stating what they were. Consequently, the Board assigns no probative weight to the June 2018 VA medical opinion. Resolving reasonable doubt in favor of the Veteran, the Board finds that the lay and medical evidence establishes that the Veteran’s right-hand osteoarthritis began during active duty service, and probative lay evidence establishes that there has been continuity of symptomatology since service. Consequently, the Board finds that in-service onset of osteoarthritis of the right hand and continuity of symptomatology is established; there is no evidence to the contrary. Accordingly, causal relationship is established on a presumptive basis, and service connection for osteoarthritis, right hand, is warranted. REASONS FOR REMAND 1. Entitlement to service connection for a skin disability. In his March 2004 claim, the Veteran sought service connection for a rash. The question for the Board, therefore, is whether the Veteran has a current skin disability that began during service or is at least as likely as not related to service. In May 2012, the Veteran was afforded a VA examination for skin diseases, during which the infectious skin condition tinea cruris, resolved, was noted. The Veteran reported that he broke out on his arms when the oil wells were on fire in Asia. He reported flare ups every other month or so, lasting a couple of days, usually during the summer. It was noted that there was no tinea cruris at the time of the examination. It was recorded that, in the past 12 months, the Veteran had used over-the-counter topical corticosteroid for six weeks or more, but not constant. It was recorded that he also had used Gold Bond and Lubriderm lotions. On examination, it was noted that the Veteran’s arms were “somewhat dry-xerosis.” The percent of total body area was less than five percent and the percent of exposed area affected was zero. It was stated that there was one red papule in the right antecubital space and one dried scab on the right forearm, both about one millimeter, which were not enough to characterize as a rash. The examiner stated: “There is currently no skin disorder that can be attributed to the environmental exposures from Southwest Asia/Gulf war.” In June 2018, the Veteran was afforded another VA examination for skin diseases, during which it was noted that he had multiple seborrheic keratoses on his back and some acrochordons (skin tags) on the underside of the arms and on the flank areas. The Veteran reported having had a rash on the anterior upper thigh and the groin while in Korea and on the right arm while at Moody Air Force Base. He reported that the last time he had been examined in support of his claim “‘the lady saw my rash on my arm.’” He stated that he had not been evaluated or treated for the condition, which he described as “‘red and itchy;’” he denied having any lesions. Seborrheic keratoses and acrochordons were diagnosed. The Veteran’s service treatment records show that in June 1973 the Veteran complained of a rash in the pubic area, which was reddened eczema and diagnosed as “jock itch.” The records show he was seen in September 1977 for a rash in the genital area, which was noted as an erythematous rash in the groin area that was worsened by sweating. Tinea cruris was diagnosed for which Desenex powder and Lotrimin cream were prescribed. In December 1981, the Veteran was diagnosed with tinea pedis and prescribed Lotrimin cream for a split between his little toe and the next on his right foot. In June 1982, tinea cruris was diagnosed again for erythematous eruptions on the Veteran’s thighs. Tinactin was prescribed. The Veteran’s military personnel records show that he had multiple deployments to Saudi Arabia during 1992 and 1993. As the Veteran’s service treatment records document in-service diagnosis and prescribed treatment of tinea cruris and related conditions in multiple areas of the body, the Board finds that there was an in-service injury, event, or disease. The May 2012 VA examiner did not opine as to whether the Veteran’s tinea cruris was directly related to his active duty service but the in-service diagnosis was reiterated during the examination, and the examiner documented the presence of a remnant of a skin disruption consistent with the Veteran’s reported symptomatology of tinea cruris. During his June 2018 VA examination, the Veteran stated that what was observed during the May 2012 VA examination was the symptomatology consistent with what he experienced during service. During the Veteran’s April 2017 hearing, he stated that he first noticed a rash during his first tour in Saudi Arabia, after the bombing. He stated that the rashes that really showed were on his arms, and he had a rash on one leg. He stated that he went to sick call for it. He stated that it recurred “maybe once a month” or “once every six months.” He stated that it continued throughout the rest of his military career. He stated that he used the cream he was given, which was “pretty much over the counter cream.” He stated that it continued until he was sent for a VA examination, and, now, he continues to use over-the-counter creams on it. He stated it occurs on his arms “maybe once a month, once six-months.” He stated that he did not see a doctor for his skin condition. The June 2018 VA examiner diagnosed seborrheic keratoses and acrochordons, stating: “A more precise diagnosis cannot be rendered as there is no objective data to support a more definitive diagnosis.” It was opined that the Veteran’s current skin conditions were not incurred in or aggravated by service. It was explained that there was no evidence of a chronic skin condition diagnosed or treated in service or within one year of separation from service. It was explained that skin tags are a common, benign outgrowth of normal skin, occurring in 50 percent of adults with frequency increasing with age. It was noted that they are frequently seen in obese patients or those with diabetes mellitus, occurring in sites of frictions. Seborrheic keratoses are common epidermal skin tumors that appear during adult life as a common sign of aging. Although their precise cause is unknown, they are considered degenerative in nature, and as time goes by, their number becomes more numerous. It was stated that researchers have noted a genetic predisposition, although the precise inheritance pattern is unknown. Based on the current evidence, the Board is unable to determine whether service connection is warranted. The main issue is the current nature of the Veteran’s skin disability. The 2012 VA examination indicated that tinea cruris had resolved and later evidence does not show whether he currently suffers from such a disability. The June 2018 VA examiner identified only age-related skin changes during the examination. Therefore, another examination is necessary determine the current nature and etiology of any skin disabilities. 2. Entitlement to service connection for left hand disability is remanded. In his March 2004 claim, the Veteran sought service connection for “knuckles pain in joints,” which has been construed as a claim for service connection for right and left hand disabilities. Private medical records from Dr. O.E.A. show that the Veteran was seen in February 2014 for bilateral hand pain, but no diagnosis was assigned to the Veteran’s left hand disability although he was referred to a rheumatologist for his bilateral hand pain. The Veteran’s service treatment records show that in January 1995 the Veteran was seen for soreness stiffness in PIPs, MCPs of hands of some days’ duration. It was noted minimal tender PIPs, MCPs both hands, and there was good range of motion. The diagnosis was probable degenerative joint disease and Naprosyn was prescribed. On his March 1996 report of medical history for retirement, the Veteran indicated Yes to the following three questions: (1) swollen or painful joints, (2) arthritis, rheumatism, or bursitis, and (3) bone, joint, or other deformity. The medical officer made notations concerning the status of the Veteran’s right-hand condition but there was no notation as to the left hand. The evidence establishes that the Veteran was stationed in Korea and continuously exposed to cold. In June 2018, the Veteran was afforded a VA examination for hand and finger conditions, during which left hand strain was diagnosed. This was based upon the Veteran’s report of constant pain in PIP and MCP joint of left index and long finger. The Veteran reported in-service exposure to cold while stationed in Korea and cold weather currently triggers increased left hand pain. It was indicated that initial range of motion of the left hand was normal; there were no gaps between the pad of the thumb and the fingers or between the finger and proximal transverse crease of the hand on proximal finger flexion; no pain was noted on examination during use or on palpation; and there was no additional functional loss after repetitive use testing of the left hand. Testing of the left hand revealed normal strength and the lack of atrophy and ankylosis. The examiner cited the X-rays of the Veteran’s left hand taken at Moody Air Force Base that revealed soft tissue normal, no bony abnormalities, no fractures seen. Joint findings: normal. The examiner opined that the Veteran’s left hand strain was not due to, caused by, or aggravated by service. As addressed above, the examiner incorrectly stated that the Veteran’s bilateral hand pain had resolved by the time of separation from service. The examiner also stated that “there are multiple other aging/occupational/daily activity factors in the intervening years.” The examiner, however, failed to identify those factors. The Board finds the June 2018 VA medical opinion problematic because it fails to identify the evidence upon which the diagnosis of left hand strain is based and it fails to provide a fully articulated rationale to support the opinion. Additionally, the examiner’s comments addressing whether the Veteran’s symptoms may constitute a qualifying chronic disability pursuant to 38 C.F.R. § 3.317 are unsatisfactory as they are not clearly responsive to the questions framed in the Board’s December 2017 remand. Consequently, the evidence of record in its current state of development is not sufficient to fully inform the Board as to the nature and etiology of the Veteran’s left hand disability, and the Board is prohibited from exercising its own independent judgment to resolve medical questions. Douglas v. Shinseki, 23 Vet. App. 19 (2009); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). On remand, a new VA examination is required to determine the nature and etiology of the Veteran’s left hand disability, taking into account his service-connected right-hand osteoarthritis, the record evidence, and accepted medical principles. 38 C.F.R. § 3.159(c)(4). 3. Entitlement to service connection for a back disability is remanded. In the Veteran’s March 2004 claim, he sought service connection for back muscle pain. Private medical records show that in January 2015 the Veteran was seen by Dr. J.E.McG. for follow up on a complaint of low back pain. The records show that in December 2014 he had been prescribed cyclobenzaprine, methocarbamol, and naproxen. It was recorded that, based upon an MRI, he would be a candidate for decompression and fusion, including L3-L4 and a construct due to the presence of adjacent segment arthritis. Accordingly, the Veteran is found to have a current disability. The Board notes that neither Dr. J.E.McG.’s complete medical records nor a copy of the MRI report are associated with the claims file. The Veteran’s service treatment records show that in November 1972 he ran into a gym wall while playing basketball and complained of lumbar pain thereafter. Moderate paravertebral spasm and tenderness over the lumbar area were documented, and medication was prescribed. He was placed on temporary profile to January 1973. When the Veteran was re-evaluated in January 1973, low back pain was noted as a recurrence. On his March 1996 report of medical history for retirement, the Veteran denied recurrent back pain. The Veteran’s military personnel records show that he first traveled to Korea in March 1975, with later service in 1978 to 1979 and in the 1980s. During his April 2017 hearing, the Veteran stated that, during service, he ran into a cinder block wall while playing basketball. He stated that he was taken to the hospital where X-rays were taken, which did not show any broken bones, but he was given pain pills. He stated that “about every three months” he went back and was given pain pills. He stated that when he was assigned to go to Korea, the airplane ride aggravated his back. He stated that, while in Korea, he went to the hospital, X-rays were taken, and he was given pain pills. He stated he was given an injection, and then, it would hurt every four or five years. He stated that he was sent for physical therapy and given a “big heating pad.” Repeated X-rays did not reveal anything. He stated that the pain became excruciating such that he was sent to a specialist, who requested an MRI. A problem was found, he was prescribed medication, and he was advised that it would be corrected only with surgery. First, the evidence establishes that medical records are missing from the claims file thereby necessitating remand for attempts to obtain those records. 38 C.F.R. § 3.159(c); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Efforts must be made to obtain all the medical records, including MRI reports, from Dr. J.E.McG, who saw the Veteran in 2014 and 2015. Efforts must be made to obtain all the Veteran’s military medical records, including any separate military and civilian hospital records, from when he was stationed in Korea and at Moody Air Force Base. Efforts must be made to identify and obtain any VA medical records pertaining to the Veteran’s back disability. Second, in June 2018, the Veteran was afforded a VA examination for back (thoracolumbar spine) conditions, during which a diagnosis of lumbar paravertebral muscle sprain was diagnosed. The Veteran reported a medical history consistent with his hearing statements, notably treatment for back pain while in Korea and at Moody Air Force base, which included medication, X-rays, massages, physical therapy, and TENS unit. The examiner stated that, based on the January 2015 private medical record, “it is safe to assume veteran has a degenerative process of the spine.” The examiner opined that it was less likely than not that the Veteran’s back disability was related to service because his service treatment records show that his in-service back muscle sprain was resolved at the time of retirement from active duty service. It was stated that low back symptoms complained of forty-plus years after service could not “reasonably be connected to AD service when there are multiple other aging/occupational/daily activity factors in the intervening years.” It was stated: “History of intercurrent injury is unknown.” It was also stated that there was no objective evidence of continuity of symptoms since service. The Board finds the June 2018 VA medical opinion inadequate thereby necessitating remand for a new VA examination. Although the examiner noted the 2015 medical records recommending surgery to treat the Veteran’s back disability, the examiner applied the in-service diagnosis of lumbar paravertebral muscle sprain as a diagnosed current disability. In opining that it was less likely than not that the Veteran’s current back disability, which appears degenerative in nature, was related to service, the examiner did not address that the initial in-service injury involved blunt trauma from hitting a cinder block wall. Additionally, while the examiner referenced “multiple other aging/occupational/daily activity factors in the intervening years,” none were identified. In forming the opinion that there was no objective evidence of continuity of symptoms since service, the examiner did not consider the Veteran’s reported medical history, which he is competent to provide, without first articulating a basis for finding it not probative. The Veteran is competent to report his symptoms and, due to the consistency of his statements, the Board finds his statements credible. See 38 C.F.R. § 3.159(a)(1)–(2); Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469–70 (1994); Caluza v. Brown, 7 Vet. App. 498, 511 (1995); see also Miller v. Wilkie, 18-2796 (CAVC Jan. 16, 2020). As noted above, pertinent medical records have not been associated with the claims file such that the June 2018 VA examiner did not have all the facts for consideration. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Accordingly, a remand is required for a new VA examination to determine the nature and etiology of the Veteran’s back disability, taking into account the record evidence and accepted medical principles. 38 C.F.R. § 3.159(c)(4). 4. Entitlement to service connection for right ear hearing loss, to include as secondary to service-connected left ear hearing loss, is remanded. In the Veteran’s March 2004 claim, the Veteran sought service connection for bilateral hearing loss. In a July 2019 rating decision, the RO granted service connection for left ear hearing loss. In a January 2020 post-remand brief, the Veteran’s representative raised the contention that the Veteran’s right ear hearing loss should be service-connected as secondary to his service-connected left ear hearing loss. A medial opinion on this theory of entitlement is required. Additionally, the Veteran’s service treatment records show that, during an annual occupational physical examination in October 1993, it was recorded: “Frequently changing hearing is related to noise exposure.” In the June 2018 VA medical opinion, the examiner did not address this evidence as applied to the right ear. Accordingly, a remand is required to obtain an addendum medical opinion as to the nature and etiology of the Veteran’s right ear hearing loss, taking into account his service-connected left ear hearing loss, the record evidence, and accepted medical principles. 38 C.F.R. § 3.159(c)(4). These matters are REMANDED for the following actions: 1. Contact the Veteran and afford him the opportunity to identify by name, address, and dates of treatment or examination of any relevant medical records pertaining to his back disability, including while serving in Korea and at Moody Air Force Base and complete medical records from Dr. J.E.McG, including MRI reports. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all records of treatment or examination from all the sources listed by the Veteran (VA and private facilities) as well as service treatment records while serving in Korea which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. If any records cannot be secured, provide the required notice and opportunity to respond to the Veteran and his representative. If possible, to expedite the case, the Veteran should submit these records himself. 2. Schedule the Veteran for an appropriate examination to determine the nature and etiology of the Veteran’s skin disabilities. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including this Remand, and to indicate review of the file in the examination report. Particular attention should be given to the Veteran’s service treatment records showing treatment for various skin disabilities, outlined above. The examiner must obtain a full history from the Veteran. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Determine all diagnoses of the skin present during the appeal period, specifically determine whether the Veteran has had tinea cruris at any time during the appeal. As to each diagnosed skin disability, please indicate whether it is at least as likely as not (50 percent or greater probability) due to or aggravated by an in-service injury, event, or disease. The examiner must reconcile any opinion with the evidence of record, citing to the record as appropriate. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner must address any conflicting medical evidence of record. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Schedule the Veteran for an appropriate examination to determine the nature and etiology of the Veteran’s left hand disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including this Remand in its entirety, and to indicate review of the file in the examination report. Particular attention should be given to the Veteran’s service-connected osteoarthritis, right hand; 2014 referral to a rheumatologist for bilateral hand pain; in-service exposure to cold while stationed in Korea and treatment for bilateral hand pain; and a diagnosis of left hand strain during a June 2018 VA examination. The examiner must obtain a full history from the Veteran. It should be noted that the Veteran is competent to attest to factual matters of which she has first-hand knowledge, such as observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner must answer the following question: Is it at least as likely as not that (50 percent probability or greater) any diagnosed disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service? The examiner must reconcile any opinion with the evidence of record, citing to the record as appropriate. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner must address any conflicting medical evidence of record. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Schedule the Veteran for an appropriate examination to determine the nature and etiology of the Veteran’s back disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including this Remand, and to indicate review of the file in the examination report. Particular attention should be given to the Veteran’s service treatment records showing traumatic back injury from hitting a cinder block wall and the Veteran’s competent and credible statements of continuing symptomatology that were addressed with a variety of treatments. The examiner must obtain a full history from the Veteran. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. Please indicate whether the Veteran’s back disability is at least as likely as not (50 percent or greater probability) due to or aggravated by an in-service injury, event, or disease. The examiner must reconcile any opinion with the evidence of record, citing to the record as appropriate. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner must address any conflicting medical evidence of record. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Arrange for an addendum VA medical opinion from the June 2018 VA examiner for hearing loss and tinnitus, if available, or another equally qualified examiner to determine the nature and etiology of the Veteran’s right ear hearing loss, to include as secondary to his service-connected left ear hearing loss. The VA clinician asked to offer the opinion should thoroughly review the Veteran’s claims file and a complete copy of this Remand in conjunction with offering any opinion and note this has been accomplished in the VA examination report. The Board leaves it to the clinician’s discretion whether the Veteran should be re-examined. Particular attention should be given to the October 1993 documentation in the Veteran’s service treatment records: “Frequently changing hearing is related to noise exposure.” (a) For the Veteran’s right ear hearing loss, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or more) proximately due to an in-service injury, event, or disease, to include exposure to hazardous noise. (b) For the Veteran’s right ear hearing loss, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or more) proximately due to or aggravated beyond its natural progression by the Veteran’s service-connected left ear hearing loss. Causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio v. O’Rourke, 30 Vet. App. 74 (2018). As such, the VA examiner must provide separate findings and rationales relating to causation and aggravation. The examiner should provide an explanation based on the specific facts of the case as well as pertinent medical evidence and/or literature for any opinion rendered. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Leanne M. Innet, 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.