Citation Nr: 20021537 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 19-27 771 DATE: March 26, 2020 ORDER Entitlement to service connection for erectile dysfunction is denied. The reduction in evaluation from 40 percent to 10 percent disabling, effective January 1, 2018, for degenerative arthritis, lumbar spine, was not proper. The reduction in evaluation from 30 percent to 20 percent disabling, effective January 1, 2018, for cubital/carpal tunnel syndromes, ulnar and median nerves, right wrist, was not proper. REMANDED Entitlement to service connection for an acquired psychiatric disorder, claimed as mental health is remanded. Entitlement to an increased disability rating for degenerative arthritis, lumbar spine is remanded. Entitlement to service connection for thought process problems is remanded. Entitlement to an increased disability rating for cubital/carpal tunnel syndromes, ulnar and median nerves, right wrist is remanded. Entitlement to service connection for hypertension, claimed as high blood pressure is remanded. Entitlement to an increased disability rating for cubital/carpal tunnel syndromes, ulnar and median nerves, left wrist is remanded. Entitlement to service connection for a cerebral vascular accident, claimed as strokes and temporary ischemic attacks is remanded. Entitlement to service connection for diabetes mellitus, type II is remanded. Entitlement to service connection for speech problems is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had erectile dysfunction at any time during the relevant appeal period. 2. The reduction in evaluation from 40 percent to 10 percent disabling, effective January 1, 2018, for degenerative arthritis, lumbar spine, was not proper as an improvement in ability to function under ordinary conditions of life and work was not shown. 3. The reduction in evaluation from 30 percent to 20 percent disabling, effective January 1, 2018, for cubital/carpal tunnel syndromes, ulnar and median nerves, right wrist, was not proper as an improvement in ability to function under ordinary conditions of life and work was not shown. CONCLUSIONS OF LAW 1. The criteria for Entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. Restoration of the 40 percent disability rating for degenerative arthritis, lumbar spine, from January 1, 2018 forward is warranted. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105 (e), 3.344, 4.2, 4.1 – 4.14, 4.71a Diagnostic Code 5003-5237; see, Tucker v. Derwinski, 2 Vet. App. 201 (1992). 3. Restoration of the 30 percent disability rating for cubital/carpal tunnel syndromes, ulnar and median nerves, right wrist, from January 1, 2018 forward is warranted. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.105 (e), 3.344, 4.2, 4.1 – 4.14, 4.124a Diagnostic Code 8516, 8513; see, Tucker v. Derwinski, 2 Vet. App. 201 (1992). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training in the United States Army from May 1981 to August 1981 and then on active duty from September 1983 to June 2003. These matters come before the Board of Veterans’ Appeals (Board) on appeal from October 2017 and July 2018 ratings decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Little Rock, Arkansas. The Board notes that the Agency of Original Jurisdiction (AOJ) initially denied service connection for a CVA in a July 2016 rating decision. Within one year of that rating decisions, the Veteran submitted new evidence and requested that these matters be reopened. See, June 27, 2017 VA Form 21-526EZ. Thus, as new and material evidence was submitted within a year of the July 2016 rating decision, the Board finds that that decision did not become final. 38 C.F.R. § 3.156 (b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). On April 4, 2018, a power of attorney (POA) was executed via VA Form 21-22a, listing J. Michael Woods as the veteran’s representative. In September 2019, the Veteran’s appeal was certified to the Board. Subsequent to that certification, in a correspondence received on November 4, 2019, the Veteran’s representative submitted a letter titled “MOTION FOR WITHDRAWAL” to the Board requesting that he be allowed to withdraw as the Veteran’s representative. Pursuant to 38 C.F.R. § 20.608 (b)(2), after an appeal has been certified to the Board, a representative may not withdraw services as a representative in the appeal unless good cause is shown on motion, and motion must be in writing and must comply with the criteria set forth in 38 C.F.R. § 20.608 (b)(2). In accordance with this regulatory provision, the Motion to Withdraw Representation contained those items specified by section 20.608(b)(2), to include an explanation for his decision to withdraw representation of the Veteran, the Veteran's name and VA file number, a signed statement indicating that a copy of the motion was sent to the Veteran via U.S. mail at his current address, and proof of filing with the Board's Senior Deputy Vice Chairman at the correct address. Upon consideration of the motion, and pursuant to 38 C.F.R. § 20.608 (b)(2), the Board finds good cause for the Motion to Withdraw Representation of the claimant in his appeal before the Board. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The appellant in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See, Scott v. McDonald, 789 F.3d 1375, 1381 (Fed.Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or appellant or obtained on his or her behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See, Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). 1. Entitlement to service connection for erectile dysfunction The Veteran contends that he is entitled to service connection for erectile dysfunction. 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). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. Here, the evidence of record consistently shows that the Veteran does not have a diagnosis of erectile dysfunction. Voluminous medical records have been reviewed, none of which suggest that such a diagnosis has been rendered. The Board concludes that the Veteran does not have a current diagnosis of erectile dysfunction 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); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). While the Veteran believes he has a current diagnosis of erectile dysfunction, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. For the reasons stated above, the Board finds that the Veteran does not have diabetes mellitus nor has such been shown at any time during the pendency of his claim. Therefore, the claim fails on this basis. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Disability Ratings Reduction There is no question that a disability rating may be reduced; however, the circumstances under which rating reductions can occur are specifically limited and carefully circumscribed by regulations promulgated by the Secretary. Dofflemyer v. Derwinski, 2 Vet. App. 277, 280 (1992). 38 C.F.R. § 3.105 (e) allows for a reduction in the evaluation of a service-connected disability when warranted by the evidence, but only after following certain procedural guidelines. First, a rating action proposing the reduction must be prepared, setting forth all material facts and reasons. The Veteran must be notified at her latest address of record of the contemplated action and furnished detailed reasons, therefore. The Veteran also must be given 60 days for the presentation of additional evidence to show that compensation payments should be continued at their present level, and to request a hearing in accordance with the provisions of 38 C.F.R. § 3.105 (e)(i)(2). Whether or not a predetermination hearing was conducted, a written notice of the final action shall be issued to the Veteran setting forth the reasons for the reduction and detailing the evidence upon which it is based. 38 C.F.R. § 3.105 (e)(i)(2). The effective date of the reduction will be the last day of the month in which a 60-day period from the date of notice to the Veteran of the final action expires. 38 C.F.R. § 3.105 (e)(i)(2)(i). Substantively, the standard to be applied to a rating reduction decision depends on how long the rating has been in effect. When a rating has continued at the same rating level for five years or more, the underlying VA examination supporting a reduction must be at least as complete as the VA examination that formed the basis for the original rating, and there must be a finding that the condition at issue is not likely to return to its previous level. 38 C.F.R. § 3.344 (a), (b), (c); Kitchens v. Brown, 7 Vet. App. 320, 324 (1995). A reduction may be made if the evidence indicates that it is reasonably certain that improvement of the underlying injury or condition will be maintained under the "ordinary conditions of life." 38 C.F.R. § 3.344 (a). However, if a rating level has been in effect for less than five years, the regulatory requirements under 38 C.F.R. § 3.344 (a) and (b) are inapplicable. 38 C.F.R. § 3.344 (c). In such cases, reexamination need only show actual improvement for a reduced rating to be appropriate. See id. In considering the propriety of a reduction, the Board must focus on the evidence of record available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered for the limited purpose of determining whether the condition has demonstrated actual improvement. Cf. Dofflemyer, at 281-82. Care must be taken, however, to ensure that a change in an examiner's evaluation reflects an actual change in the veteran's condition, and not merely a difference in the thoroughness of the examination or in descriptive terms, when viewed in relation to the prior disability history. In addition, it must be determined that an improvement in a disability has actually occurred, and that such improvement actually reflects an improvement in the veteran's ability to function under the ordinary conditions of life and work. See 38 C.F.R. §§ 4.1, 4.2, 4.13; see also, Brown v. Brown, 5 Vet. App. 5 Vet. App. 413, 420-22 (1993); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Moreover, if the VA examination report justifying the rating reduction is inadequate, the reduction cannot be upheld. See, Tucker v. Derwinski, 2 Vet. App. 201 (1992) (holding that the failure of the examiner in that case to review the claims file rendered the reduction decision void ab initio). Significantly, in a rating reduction case, VA has the burden of establishing that the disability has improved. This is in stark contrast to a case involving a claim for an increased (i.e., higher) rating, in which it is the Veteran's responsibility to show the disability has worsened. A rating reduction case focuses on the propriety of the reduction and is not the same as an increased rating issue. See, Peyton v. Derwinski, 1 Vet. App. 282, 286 (1991). 2. Whether the reduction in disability rating from 40 percent to 10 percent disabling, effective January 1, 2018, for degenerative arthritis, lumbar spine, was proper The Veteran contends that the reduction is disability rating from 40 percent to 10 percent disabling, effective January 1, 2018 forward was improper. By way of procedural history, the Veteran was service connected for degenerative arthritis of the lumbar spine at 10 percent disabling, effective July 1, 2003. In a September 2013 rating decision, a 40 percent disability rating was granted, effective June 7, 2012. This rating was continued in an April 2015 rating decision. In an October 2017 rating decision, the disability rating was reduced to 10 percent, effective January 1, 2018. Here, the 40 percent rating was in effect for over 5 years. The Veteran was afforded a VA thoracolumbar spine examination in February 2015. A diagnosis of degenerative arthritis of the lumbar spine was noted. The Veteran reported increasing pain that was constant in the low back without radiculopathy. Upon examination, initial range of motion was measured as follows: 0 to 70 degrees forward flexion; 0 to 20 degrees extension; 0 to 30 degrees right lateral flexion; 0 to 25 degrees left lateral flexion; 0 to 30 degrees right lateral rotation; and 0 to 25 degrees left lateral rotation. It was noted that neither pain nor range of motion contribute to a functional loss. No evidence of pain with weight bearing was noted, nor was localized pain or tenderness on palpation. After repetitive use testing, no additional loss of function or range of motion were noted. It was further noted that neither pain, weakness, fatigability nor incoordination significantly limit functional ability with repeated use over a period of time or with flare-ups. It was noted that the exam was not being conducted during a flare-up. Neither guarding nor muscle spasm were noted. Neither IVDS nor radiculopathy were noted. Occasional use of a cane was noted. The examiner noted that the Veteran’s condition limited his standing to 15 minutes and his walking to 200 yards. The Veteran was afforded a VA thoracolumbar spine examination in January 2017. A diagnosis of degenerative arthritis of the spine was noted. The Veteran reported that his back had been stable with continued pain and stiffness. He further reported that he is able to do some work in his yard, including mowing it with a riding mower. He reported occasional flare-ups where he has difficulty standing up straight. Regarding functional impact, the Veteran reported that he can walk 200 to his mailbox and back and can do whatever he wants to do. Upon examination, initial range of motion was measured as follows: 0 to 70 degrees forward flexion; 0 to 10 degrees extension; 0 to 20 degrees right lateral flexion; 0 to 20 degrees left lateral flexion; 0 to 35 right lateral rotation; and 0 to 25 left lateral rotation. While the range of motion was noted as causing a functional loss, pain was noted as causing a functional loss on all measurements except right lateral rotation. Mild pain was noted on palpation of the right lumbar. After repetitive use testing, no additional loss of function or range of motion were noted. Pain with weight-bearing, non-weight bearing, and passive range of motion was noted, but does not result in a functional loss. Here, the Board notes that no VA examiner has made a finding that the apparent improvement in the Veteran’s lumbar spine reflected an improvement in ability to function under the ordinary conditions of life and work. Indeed, there is no evidence that shows that the Veteran could walk more than 200 yards at a time. While he reported that he is able to do some yardwork, the example of yardwork that was provided was an ability to use a riding mower. Further, the January 2017 examination actually showed a worsening range of motion in extension, and right and left lateral flexion. Furthermore, the Board notes that neither examination provided the measurements regarding where pain on range of motion occurred. As such, the Board finds that the February 2015 and January 2017 VA examinations are inadequate. If the VA examination report justifying the rating reduction is inadequate, the reduction cannot be upheld. See, Tucker v. Derwinski, 2 Vet. App. 201 (1992) (holding that the failure of the examiner in that case to review the claims file rendered the reduction decision void ab initio). Here, the evidence of record is such that the Board finds that neither VA examination showed an improvement in ability to function under ordinary conditions of life and work and, as such, the reduction in rating from 40 percent to 10 percent was improper. Restoration of the Veteran’s 40 percent rating for degenerative arthritis, lumbar spine from January 2018 forward is warranted. 3. whether the reduction in disability rating from 30 percent to 20 percent disabling, effective January 1, 2018, for cubital/carpal tunnel syndromes, ulnar and median nerves, right wrist, was proper The Veteran contends that the reduction is disability rating from 30 percent to 20 percent disabling, effective January 1, 2018 forward was improper. By way of procedural history, the Veteran was service connected for cubital/carpal tunnel syndromes ulnar and median nerve, right wrist at 10 percent, effective July 1, 2003. In a September 2013 rating decision, the disability rating was increased to 30 percent, effective June 7, 2012. This rating was continued in an April 2015 rating decision. In an October 2017 rating decision, the diagnostic code was changed from DC 8516, the Ulnar nerve, to DC 8513, dealing with all radicular nerves, and the disability rating was reduced to 20 percent effective January 1, 2018. Here, the 30 percent rating was in effect for over 5 years. The Veteran was afforded a VA peripheral nerves conditions examination in February 2015. A diagnosis of bilateral cubital tunnel syndrome with carpal tunnel syndrome was noted. The Veteran reported tingling in his small and ring fingers, with the left being worse than the right. He was noted as being right hand dominant. Mild right upper extremity paresthesias were noted. Muscle, reflex and sensory testing were normal. The Veteran was afforded a VA peripheral nerves conditions examination in January 2017. Diagnoses of carpal and cubital tunnel syndrome were noted. The Veteran reported no change in symptoms was noted. Mild right upper extremity paresthesias and numbness were noted. Muscle, reflex and sensory testing were normal. Here, the Board notes that no VA examiner has made a finding that the apparent improvement in the Veteran’s right wrist reflected an improvement in ability to function under the ordinary conditions of life and work. In fact, both the February 2015 and January 2017 VA examiners failed to describe the functional impact of the Veteran’s right wrist condition beyond checking a box indicating there is no effect on his ability to work. As such, the Board finds that the February 2015 and January 2017 VA examinations are inadequate. If the VA examination report justifying the rating reduction is inadequate, the reduction cannot be upheld. See, Tucker. Here, the evidence of record is such that the Board finds that neither VA examination showed an improvement in ability to function under ordinary conditions of life and work and, as such, the reduction in rating from 30 percent to 20 percent was improper. Restoration of the Veteran’s 30 percent rating for cubital/carpal tunnel syndromes, ulnar and median nerves, right wrist from January 2018 forward is warranted. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder, claimed as mental health is remanded. The Veteran has asserted entitlement to service connection for an acquired psychiatric disorder, claimed as mental health. The Board notes that the Veteran asserted exposure to environmental hazards from the Gulf War while he was stationed in Kuwait in his June 2017 claim form. The Board further notes that a November 29, 2017 VA treatment record notes the Veteran acknowledged having episodes of depression and anxiety, primarily related to his decline in functioning brought on by his cerebral vascular accidents, also claimed for service connection. He was diagnosed with unspecified depressive disorder. According to McLendon v. Nicholson, 20 Vet. App. 79 (2006), when required to adequately adjudicate the claim, VA must provide a medical examination assessing the Veteran's claimed disabilities or conditions. Here, the Board finds a remand for a VA examination is required to adequately adjudicate this claim. 2. Entitlement to an increased disability rating for degenerative arthritis, lumbar spine is remanded. The Board notes that the veteran was last afforded a VA examination for rating purposes for his degenerative arthritis, lumbar spine in January 2017. As such, the need for a thorough and contemporaneous evaluation, as well as the age of the last examination, weigh in favor of remand for a new examination. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); see also, Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991) (observing that where the record does not adequately reveal the current state of the claimant's disability, a VA examination must be conducted); see also 38 C.F.R. § 3.326 (a). 3. Entitlement to service connection for thought process problems is remanded. VA treatment records indicate that since his August 2015 cerebral vascular accident, the Veteran has had problems with trying to think of words when he is talking. As the Veteran is pursuing service connection for his August 2015 cerebral vascular accident, the Board finds that an examination is also required to properly adjudicate this claim. McClendon. 4. Entitlement to an increased disability rating for cubital/carpal tunnel syndromes, ulnar and median nerves, right wrist is remanded. The Board notes that the veteran was last afforded a VA examination for rating purposes for his cubital/carpal tunnel syndromes, ulnar and median nerves, right wrist in January 2017. As such, the need for a thorough and contemporaneous evaluation, as well as the age of the last examination, weigh in favor of remand for a new examination. Weggenmann; Schafrath. See also 38 C.F.R. § 3.326 (a). 5. Entitlement to service connection for hypertension, claimed as high blood pressure is remanded. The Board notes that numerous service treatment records show elevated blood pressure readings. As such, the Board finds that a VA examination is required to properly adjudicate this claim. McClendon. 6. Entitlement to an increased disability rating for cubital/carpal tunnel syndromes, ulnar and median nerves, left wrist is remanded. The Board notes that the veteran was last afforded a VA examination for rating purposes for his cubital/carpal tunnel syndromes, ulnar and median nerves, left wrist in January 2017. As such, the need for a thorough and contemporaneous evaluation, as well as the age of the last examination, weigh in favor of remand for a new examination. Weggenmann; Schafrath. See also 38 C.F.R. § 3.326 (a). 7. Entitlement to service connection for a cerebral vascular accident, claimed as strokes and temporary ischemic attacks is remanded. The Veteran asserts he is entitled to service connection for his August 2015 cerebral vascular accident and its residuals. The Board notes that in his June 2017 claim form, the Veteran asserted exposure to environmental hazards from the Gulf War when he was stationed in Kuwait. As such, the Board finds that an examination is required to properly adjudicate this claim. McClendon. 8. Entitlement to service connection for diabetes mellitus, type II is remanded. The Veteran asserts he is entitled to service connection for his diabetes mellitus, type II. The Board notes that in his June 2017 claim form, the Veteran asserted exposure to environmental hazards from the Gulf War when he was stationed in Kuwait. As such, the Board finds that an examination is required to properly adjudicate this claim. McClendon. 9. Entitlement to service connection for speech problems is remanded. VA treatment records indicate that since his August 2015 cerebral vascular accident, the Veteran has had problems with speaking. As the Veteran is pursuing service connection for his August 2015 cerebral vascular accident, the Board finds that an examination is also required to properly adjudicate this claim. McClendon. 10. Entitlement to service connection for obstructive sleep apnea is remanded. The Veteran asserts he is entitled to service connection for his August 2015 obstructive sleep apnea. The Board notes that in his June 2017 claim form, the Veteran asserted exposure to environmental hazards from the Gulf War when he was stationed in Kuwait. As such, the Board finds that an examination is required to properly adjudicate this claim. McClendon. The matters are REMANDED for the following action: Acquired Psych 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including claimed exposure to claimed Gulf War environmental hazards while stationed in Kuwait. The examiner must opine as to whether it is at least as likely as not (1) proximately due to claimed cerebral vascular accident, or (2) aggravated beyond its natural progression by claimed cerebral vascular accident. Lumbar Spine 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected degenerative arthritis, lumbar spine. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Thought Process 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any thought process problems. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including claimed exposure to Gulf War environmental hazards. The examiner must opine as to whether it is at least as likely as not (1) proximately due to claimed cerebral vascular accident, or (2) aggravated beyond its natural progression by claimed cerebral vascular accident. Right Wrist 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected cubital/carpal tunnel syndromes, ulnar and median nerves, right wrist. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Hypertension 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any hypertension. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including in-service elevated blood pressure readings. The examiner must opine as to whether it at least as likely as not (1) began during active service, or (2) was noted during service with continuity of the same symptomatology since service. The examiner’s attention is invited to the following service treatment records showing elevated blood pressure readings: June 29, 1993 - 120 systolic over 80 diastolic. October 12, 2000 - 149 systolic over 82 diastolic. May 15, 2002 - 128 systolic over 80 diastolic. August 26, 2002 - 142 systolic over 82 diastolic. January 30, 2003 - 145 systolic over 80 diastolic. The examiner must address whether the elevated blood pressure readings in service were prodromal to the Veteran’s eventual post-service diagnosis of hypertension. Left Wrist 6. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected cubital/carpal tunnel syndromes, ulnar and median nerves, left wrist. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). In so doing, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Cerebral Vascular Accident 7. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any cerebral vascular accident. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including claimed exposure to Gulf War environmental hazards. The examiner must opine as to whether it is at least as likely as not (1) proximately due to claimed hypertension, or (2) aggravated beyond its natural progression by claimed hypertension. Diabetes 8. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any diabetes mellitus, type II. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including claimed exposure to Gulf War environmental hazards. The examiner must opine as to whether it is at least as likely as not (1) proximately due to claimed hypertension, or (2) aggravated beyond its natural progression by claimed hypertension. Speech Problems 9. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any speech problems. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including claimed exposure to Gulf War environmental hazards. The examiner must opine as to whether it is at least as likely as not (1) proximately due to a claimed cerebral vascular accident, or (2) aggravated beyond its natural progression by a claimed cerebral vascular accident. Sleep Apnea 10. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any obstructive sleep apnea. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including claimed exposure to Gulf War environmental hazards. 11. All opinions provided must be thoroughly explained, and a complete and detailed rationale for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate). The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. 12. After completing the requested actions, and any additional development deemed warranted, readjudicate the claims in light of all pertinent evidence and legal authority. If the benefits sought remain denied, furnish to the Veteran a Supplemental Statement of the Case and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. C. TRUEBA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Brian P. Keeley 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.