Citation Nr: 20045596 Decision Date: 07/08/20 Archive Date: 07/08/20 DOCKET NO. 14-07 430 DATE: July 8, 2020 ORDER Entitlement to service connection for joint pain is dismissed. Entitlement to service connection for fatigue is denied. Entitlement to service connection for insomnia is denied. Entitlement to service connection for an upper respiratory disorder is denied. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to a service connection for a sinus disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to a right knee disability, is remanded. Entitlement to service connection for hypertension, to include as secondary to a right knee disability, a sinus disorder, and/or an acquired psychiatric disorder, is remanded. Entitlement to service connection for headaches, to include as secondary to a sinus disorder, hypertension, and/or an acquired psychiatric disorder, is remanded. Entitlement to service connection for a stomach disorder, to include gastroesophageal reflux disease (GERD), to include as secondary to a sinus disorder, is remanded. Entitlement to service connection for sleep apnea, to include as secondary to a sinus disorder and/or an acquired psychiatric disorder, is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to an acquired psychiatric disorder, is remanded. FINDINGS OF FACT 1. There is no justiciable case or controversy before the Board at this time with respect to the issue of entitlement to service connection for joint pain. 2. The Veteran does not have a current diagnosis of chronic fatigue syndrome or any other separately-diagnosed disability manifested by fatigue; his symptoms of fatigue are subsumed by his sleep apnea. 3. The Veteran does not have a separately-diagnosed sleep disorder manifested by insomnia; his symptoms of insomnia are subsumed by his unspecified anxiety disorder. 4. The Veteran does not have a currently-diagnosed upper respiratory disorder. CONCLUSIONS OF LAW 1. The appeal as to entitlement to service connection for joint pain is dismissed. 38 U.S.C. § 7105. 2. The criteria for entitlement to service connection for fatigue have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for insomnia have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for an upper respiratory disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from October 1992 to January 1995. He had additional service in the Texas Air National Guard and the United States Air Force Reserve. These matters are before the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued in August 2010, September 2010, December 2011, and August 2014 by the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded these matters for additional development in February 2018. The Board notes that since the April 2020 supplemental statement of the case (SSOC), additional VA treatment records were associated with the Veteran’s claims file. However, as this evidence is either not relevant to the Veteran’s claims or duplicative of the existing evidence of record, the Board may proceed to adjudicate the appeal with no prejudice to the Veteran. Duties to Notify and Assist With respect to the Veteran’s claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159. The Veteran has not advanced any procedural arguments in relation to VA’s duties to notify and assist; therefore, the Board will proceed with appellate review. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). In general, service connection requires: (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of an in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge when all evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). 1. Entitlement to service connection for joint pain The Veteran seeks entitlement to service connection for joint pain. The Board notes that the Veteran did not file a formal claim for joint pain; rather, the RO determined that it had been raised by the record due to numerous lay statements by the Veteran in which he described experiencing unspecified pain. The RO adjudicated the issue accordingly. In October 2019, VA contacted the Veteran by telephone to request that he clarify the anatomic location of his joint pain. He stated that his joint pain is in his knees and back. The Board notes that the Veteran was already denied service connection for a back disorder in a February 2018 Board decision. The Veteran did not appeal or request reconsideration of this decision. With regard to the knees, the Veteran currently has a separate appeal pending for the issue of entitlement to service connection for a right knee disability that manifests by pain (discussed herein). Moreover, the medical evidence does not indicate, and the Veteran has not argued, that he has ever reported or sought medical treatment for left knee pain or has a currently-diagnosed left knee condition. Finally, there are no other statements from the Veteran as to any other anatomic locations where he experiences joint pain. Given the foregoing, the Board cannot identify any case or controversy for it to adjudicate with respect to the claim for entitlement to service connection for joint pain. See Shoen v. Brown, 6 Vet. App. 456, 457 (1994) (a case or controversy must exist in order to obtain appellate review); see also 38 U.S.C. § 7105(d)(5) (the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed). Accordingly, the Board finds that the claim as to entitlement to service connection for joint pain must be dismissed. 2. Entitlement to service connection for fatigue 3. Entitlement to service connection for insomnia The Veteran seeks entitlement to service connection for fatigue and insomnia, which he contends were caused by the anthrax vaccine he received during service. Alternatively, he argues that fatigue and insomnia are proximately due to or caused by pain from his right knee disability, sleep apnea, and/or anxiety (the Board notes that these issues are currently on appeal for service connection). The Veteran’s service treatment records have been associated with the claims file. They include his July 1992 enlistment examination and February 1995 separation examination, both of which document clinically normal evaluations. Moreover, the service treatment records do not contain any complaint, treatment, or diagnosis for insomnia, fatigue, or any symptoms related to a sleep disorder during service. The Veteran’s post-service private and VA treatment records show that the Veteran has sought treatment for insomnia. He is currently prescribed a sleep aid to take as needed. The Veteran was afforded VA examinations in December 2019. First, he was evaluated for chronic fatigue syndrome. Upon examination, the Veteran reported an onset of fatigue in approximately 2004, however the initial onset of symptoms was gradual and he did not seek treatment at the time. His current symptoms are constant tiredness, which impacts his productivity and ability to complete household chores such as yardwork. The VA examiner determined that the Veteran does not meet the criteria for a diagnosis of chronic fatigue syndrome. Moreover, the examiner noted that there was no evidence of symptoms associated with chronic fatigue at any time during military service. The examiner concluded that the Veteran’s feelings of tiredness may be related to his diagnosis of obstructive sleep apnea. The Veteran also underwent a mental disorders evaluation. Upon examination, he reported symptoms of insomnia, anxiety, and stress. After evaluating the Veteran and his reported symptoms, the VA examiner diagnosed the Veteran with unspecified anxiety disorder. The examiner concluded that the Veteran does not meet the diagnostic criteria for a separate diagnosis of a sleep disorder, finding instead that his symptom of insomnia is subsumed in his endorsed anxiety disorder. Based on a careful review of all the subjective and clinical evidence of record, the Board finds that the preponderance of the evidence weighs against finding that service connection is warranted because the Veteran is not shown to have currently-diagnosed insomnia and/or fatigue disabilities. The existence of a current disability is the cornerstone of a claim for VA disability compensation; consequently, failure to establish a current disability results in the denial of a claim. 38 U.S.C. § 1110; 38 C.F.R. § 3.303; see Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Specifically, a claimant must have a diagnosed disability in order to be considered for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, the Board finds that the evidence of record does not contain probative evidence of a diagnosis of an insomnia and/or fatigue disability at any time proximate to, or during, the appellate period. See McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). The Board acknowledges that, during the pendency of these claims, the Veteran has sought medical treatment for his symptoms of insomnia and fatigue and was provided VA examinations related to these symptoms in December 2019. The December 2019 VA examiner reviewed the record, interviewed the Veteran, and conducted an in-person examination. The VA examiner found that the Veteran does not have a current diagnosis of chronic fatigue syndrome, insomnia, or any other sleep disorder. Additionally, the VA examiner noted that the Veteran is diagnosed with unspecified anxiety disorder and obstructive sleep apnea, which may account for his sleep impairment and fatigue. Moreover, the Board acknowledges that the Veteran has reported experiencing sleep impairment, insomnia, and fatigue to his healthcare providers during the pendency of the claims. However, a complaint or symptom is not a “disability” for VA purposes. In this case, the Board cannot grant the Veteran service connection for his symptoms of insomnia or fatigue, which are subsumed by his separately-diagnosed conditions of sleep apnea and anxiety disorder. Thus, the most probative evidence fails to demonstrate that it is at least as likely as not that the Veteran has a currently-diagnosed insomnia and/or fatigue disability. The Board acknowledges the Veteran’s assertions that he has chronic insomnia and fatigue disabilities. While the Veteran is competent to report symptoms of disability, he does not have the specialized medical training to render a specific diagnosis. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, his assertions are not considered competent and do not weigh against the probative value of the medical treatment records, including the December 2019 VA examinations, which do not show a diagnosis of a separate insomnia and/or fatigue disability. Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110. In the absence of proof of current disability there can be no valid claim for service connection. See Brammer, 3 Vet. App. at 225. Thus, in the absence of competent evidence showing currently-diagnosed insomnia and/or fatigue disabilities, it is unnecessary to address the remaining elements of the claim for service connection. See id. Accordingly, the Board finds that a preponderance of the evidence weighs against the Veteran’s claims for service connection for insomnia and/or fatigue. Because the evidence fails to establish that the Veteran has currently-diagnosed insomnia and/or fatigue disabilities, the claims do not satisfy the criteria for service connection. Therefore, the benefit-of-the-doubt rule does not apply and the claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. 4. Entitlement to service connection for an upper respiratory disorder The Veteran seeks entitlement to service connection for an upper respiratory disorder. The Veteran contends that he developed a chronic upper respiratory disorder, characterized by frequent upper respiratory infections, congestion, runny nose, sore throat, and headaches, due to the anthrax vaccine he received during service. Alternatively, he argues that the upper respiratory disorder is secondary to a sinus disorder (currently-diagnosed as allergic rhinitis), which is also on appeal before the Board. The Veteran’s service treatment records have been associated with the claims file. On his July 1992 enlistment examination and February 1995 separation examination, the Veteran denied a history of chronic or frequent colds, sinusitis, or hay fever. In February 1993, he was treated for symptoms of a head cold with congestion, body aches, chills, sore throat, and runny nose; he was assessed to have viral syndrome. Post-service medical records show that the Veteran was treated for upper respiratory infections in November 1998, April 2000, and January 2011. The Veteran has also received medical treatment on several occasions for sinusitis and allergic rhinitis. The Veteran underwent a VA respiratory conditions examination in December 2019. Upon examination, the Veteran reported a history of symptoms such as headaches, congestion and drainage, and pressure behind eyes, with an onset of symptoms in 2004. He denied lower respiratory symptoms. The VA examiner confirmed a diagnosis of allergic rhinitis, but did not find the Veteran to have any chronic sinus or upper respiratory disorders. The examiner concluded that there are no objective findings, signs, or symptoms to support a current diagnosis of an upper respiratory disorder, which is pathologically unrelated to allergic rhinitis. The examiner noted that upper respiratory infections are acute conditions that resolve naturally or with short-course antibiotics. Thus, during service, the Veteran’s single episode of upper respiratory symptoms was due to an acute viral infection, which is self-limiting and resolves without residual effects. Based on a careful review of all the subjective and clinical evidence of record, the Board finds that the preponderance of the evidence weighs against finding that service connection is warranted because the Veteran is not shown to have a currently-diagnosed upper respiratory disorder. In this case, the medical evidence of record does not reflect a current diagnosis of an upper respiratory disorder, and no such diagnosis has been rendered at any time during the pendency of the appeal. See McClain, 21 Vet. App. at 319; Romanowsky, 26 Vet. App. at 289. In this regard, the Board notes that the December 2019 VA examiner determined that there is no evidence the Veteran has a current diagnosis of an upper respiratory disorder. Although the Veteran was treated for upper respiratory symptoms, which was diagnosed as a viral syndrome, during service and has been periodically diagnosed with upper respiratory infections in the years since service, these episodes were acute, self-limiting, and resolved without residuals. The Board finds it significant that the Veteran has not presented or identified any contrary medical evidence showing that he has a currently-diagnosed chronic upper respiratory disorder. Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. See 38 U.S.C. § 1110. In the absence of proof of current disability there can be no valid claim for service connection. See Brammer, 3 Vet. App. at 225. Thus, in the absence of competent evidence showing a current diagnosis of an upper respiratory disorder, it is not necessary to address the remaining elements of the claim for service connection. Finally, while the Veteran is competent to report symptoms of disability, he is not shown to have the specialized medical training required to render a diagnosis for a complex medical condition such as an upper respiratory disorder. See Layno, 6 Vet. App. at 470; Jandreau, 492 F.3d at 1372. The Veteran has not provided any other competent or credible medical evidence to establish that he has a currently-diagnosed condition. Accordingly, the Board finds that the preponderance of the evidence weighs against the Veteran’s claim for service connection for an upper respiratory disorder. Because the evidence fails to establish that the Veteran has a currently-diagnosed condition, the claim does not satisfy the criteria for service connection. Therefore, the benefit-of-the-doubt rule does not apply, and the Veteran’s claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. REASONS FOR REMAND Unfortunately, the claims remaining on appeal must be remanded once again because the RO did not substantially comply with the Board’s prior remand instructions. Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand). 1. Entitlement to service connection for a right knee disability is remanded. The Veteran seeks entitlement to service connection for a right knee disability, which he contends was incurred in service. The Veteran asserts that he injured his knee while performing additional duties, such as working 12 hour shifts in squadron warehouses packing deployment bags. The Board notes that the Veteran’s service treatment records show that the Veteran sought treatment for a swollen right knee in January 1994. At the time, he reported a history of injury to the knee while playing football about 3 years prior. The examining physician noted a diagnosis of arthritis. The Veteran underwent a VA examination in July 2010. He was diagnosed with chondromalacia of the right knee. The VA examiner provided a negative nexus opinion, but did not address the January 1994 service treatment record or the Veteran’s contentions of suffering an in-service knee injury. Pursuant to the February 2018 Board remand, the Veteran underwent another VA examination in December 2019. Upon examination, the VA examiner diagnosed him with a right knee strain and Osgood-Schlatter disease. The examiner remarked that there are no objective records of right knee symptoms during service and that the Veteran’s right knee pain began several years after service. Thus, the examiner concluded that a nexus to service cannot be established. The Board finds the December 2019 medical opinion to be inadequate. The examiner did not consider pertinent service treatment records showing that the Veteran sought treatment during service for his right knee and therefore based his opinion on an incomplete review of the evidence. Reonal v. Brown, 5 Vet. App. 458, 460 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). The Board notes that the Veteran submitted an April 2020 independent medical opinion completed by a private doctor, Dr. E., who interviewed the Veteran via telephone, but did not conduct an in-person examination. Dr. E. diagnosed the Veteran with Osgood-Schlatter disease and traumatic arthritis of the right knee, which, the doctor opined, are more likely than not due to military service. Although favorable to the Veteran, the Board cannot rely upon the above opinion as a basis to grant the Veteran’s claim for service connection because it appears to be based solely on a history provided by the Veteran and a limited number of private treatment records, rather than a complete review of the Veteran’s claims file, including his service treatment records and VA medical records. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In light of the above, the Board finds that the Veteran’s claim must be remanded once again because the RO did not comply with the Board’s prior remand directives to obtain an adequate medical opinion on the Veteran’s behalf. See Stegall, 11 Vet. App. at 268. On remand, the RO must obtain a medical opinion from a qualified medical professional that is adequate for the Board to make an informed decision on the Veteran’s claim. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Douglas v. Shinseki, 23 Vet. App. 19, 26 (2009). 2. Entitlement to service connection for a sinus disorder is remanded. The Veteran seeks entitlement to service connection for a sinus disorder, which he contends was incurred in service due to receiving an anthrax vaccine. Alternatively, the Veteran contends that he developed sinus issues during service due to exposure to asbestos, jet fuel, sewage, and/or mold due to poor living conditions at Keesler Air Force Base. Post-service medical records show that the Veteran has received regular treatment for both sinusitis and allergic rhinitis beginning in March 1998 until the present. He underwent a VA examination in May 2010 and was diagnosed with allergic rhinitis and nasal septal deviation. He was not found to have chronic sinusitis. The VA examiner opined that the Veteran’s allergic rhinitis is less likely than not related to military service as the Veteran did not have any symptoms during service. Pursuant to the February 2018 Board remand, the Veteran underwent another VA examination in December 2019. The VA examiner confirmed a diagnosis of allergic rhinitis and determined that the Veteran does not have chronic sinusitis, finding that prior diagnoses of sinusitis were acute conditions that had resolved. The examiner determined that the Veteran’s allergic rhinitis is less likely than not related to military service, however, the Board notes that the examiner did not provide a supporting rationale for this finding. As such, this opinion is inadequate. The Veteran submitted an April 2020 independent medical opinion provided by Dr. E., who opined that the Veteran has a diagnosis of chronic sinusitis that was more likely than not incurred in or caused by military service. However, as noted above, the Board cannot rely upon the favorable private opinion as a basis to grant the service connection because it appears to be based solely on a history provided by the Veteran and a limited number of private treatment records, rather than a complete review of the Veteran’s complete claims file. In light of the above, the Board notes that the record does not contain an adequate medical opinion addressing the nature and etiology of the Veteran’s sinus disorder. In this regard, an opinion has not been obtained that addresses the Veteran’s contentions that he developed a sinus disorder in service due to receiving an anthrax vaccine and/or exposure to asbestos, jet fuel, sewage, and mold. As such, the Board finds that the Veteran’s claim must be remanded once again because the RO did not comply with the Board’s prior remand directives to obtain an adequate medical opinion on the Veteran’s behalf. See Stegall, 11 Vet. App. at 268. On remand, the RO must obtain a medical opinion from a qualified medical professional that is adequate for the Board to make an informed decision on the Veteran’s claim. See Barr, 21 Vet. App. at 311-12; Douglas, 23 Vet. App. at 26. In addition, on remand, the RO should undertake appropriate efforts to attempt to verify the Veteran’s claimed in-service exposure to asbestos pursuant to the evidentiary development guidelines outlined in VA’s Adjudication Procedures Manual. See M21-1, Part IV, Subpart ii, Chapter 1, Section I, Topic 3(c). 3. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to a right knee disability, is remanded. 4. Entitlement to service connection for hypertension, to include as secondary to a right knee disability, a sinus disorder, and/or an acquired psychiatric disorder, is remanded. 5. Entitlement to service connection for headaches, to include as secondary to a sinus disorder, hypertension, and/or an acquired psychiatric disorder, is remanded. 6. Entitlement to service connection for a stomach disorder, to include GERD, to include as secondary to a sinus disorder, is remanded. 7. Entitlement to service connection for sleep apnea, to include as secondary to a sinus disorder and/or an acquired psychiatric disorder, is remanded. 8. Entitlement to service connection for erectile dysfunction, to include as secondary to an acquired psychiatric disorder, is remanded. The Veteran seeks entitlement to service connection for an acquired psychiatric disorder, hypertension, headaches, a stomach disorder, sleep apnea, and erectile dysfunction. The Veteran contends that these disabilities are a result of his service, which he states included an anthrax vaccine and exposure to asbestos, jet fuel, sewage, and mold. In its February 2018 remand, the Board directed the RO to obtain VA medical opinions to address the Veteran’s theory of entitlement to direct service connection. Although medical opinions as to these issues were obtained in December 2019 and February 2020, the VA examiners either did not address the Veteran’s contentions with regard to the anthrax vaccine or stated that current medical literature does not support a link between the anthrax vaccine and the claimed disability, despite the existence of favorable medical literature in the claims file that was submitted by the Veteran. Moreover, the VA examiners did not provide opinions at all with regard to the Veteran’s claimed exposure to asbestos, jet fuel, sewage and mold. As such, the Board finds that the claims must be remanded once again because the RO did not comply with the Board’s prior remand directives to obtain adequate medical opinions on the Veteran’s behalf. See Stegall, 11 Vet. App. at 268. On remand, the RO must obtain addendum opinions from qualified medical professionals that are adequate for the Board to make informed decisions on the Veteran’s claims. See Barr, 21 Vet. App. at 311-12; Douglas, 23 Vet. App. at 26. Finally, the Veteran has indicated that these disabilities are secondary to other claimed disabilities. Therefore, the Board finds that the Veteran’s acquired psychiatric disorder, hypertension, headaches, stomach disorder, sleep apnea, and erectile dysfunction are inextricably intertwined with the Veteran’s claims for a right knee disorder, a sinus disorder, acquired psychiatric disorder, and hypertension being remanded herein. For this reason, those disabilities must be resolved prior to resolution of the claims for an acquired psychiatric disorder, hypertension, headaches, sleep apnea, erectile dysfunction, and stomach disorder. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following actions: 1. Following the procedures outlined at M21-1, IV.ii.1.I.3.c., and based on a review of the Veteran’s military occupational specialty and occupational exposure, make a formal finding regarding the likelihood that the Veteran was exposed to asbestos during service. 2. Then, forward the Veteran’s claims file to VA examiner(s) of appropriate expertise who have not previously provided an opinion in this appeal to provide addendum medical opinions addressing the nature and etiology of the Veteran’s claimed disabilities of: (i) a right knee disability; (ii) a sinus disorder; (iii) an acquired psychiatric disorder; (iv) hypertension; (v) headaches; (vi) a stomach disorder; (vii) sleep apnea; and (viii) erectile dysfunction. A full VA examination should not be scheduled unless it is deemed necessary by the examiner or otherwise required by the evidence. Each respective examiner must review the claims file in its entirety and note that review in the examination report. Thereafter, the respective examiner should provide a detailed medical opinion addressing the following: Right Knee Disability (a) Set forth all currently-diagnosed right knee disabilities, including those diagnosed during the pendency of the appeal (i.e. chondromalacia, strain, and Osgood-Schlatter disease), even if currently resolved. (b) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed right knee disability was incurred in or caused by an in-service injury, illness, or event? The requested opinion must specifically consider and address the relevance of the January 1994 service treatment record documenting that the Veteran sought treatment for a swollen right knee and was diagnosed with arthritis. Sinus Disorder (a) Set forth all currently-diagnosed sinus disorders, including those diagnosed during the pendency of the appeal (i.e. sinusitis and allergic rhinitis), even if currently resolved. (b) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed sinus disorder was incurred in or caused by an in-service injury, illness, or event? The requested opinion must specifically consider the Veteran’s contentions that he developed symptoms of a sinus disorder during service due to receiving the anthrax vaccine and/or after exposure to jet fuel, asbestos, and/or mold. In this regard, the examiner must address the following evidence in the claims file: (i) Anthrax Vaccine: What You Need to Know; (ii) Anthrax Shot Symptoms and Illnesses, Veterans Benefits Network; (iii) Anthrax Vaccine: A Resource for Veterans, Service Members, and their Families, War-related Illness and Injury Study Center, Department of Veterans Affairs. Acquired Psychiatric Disorder (a) Set forth all currently-diagnosed acquired psychiatric disorders, including those diagnosed during the pendency of the appeal (i.e. unspecified anxiety disorder), even if currently resolved. (b) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed acquired psychiatric disorder was incurred in or caused by an in-service injury, illness, or event? In responding to the above, the examiner must specifically address the Veteran’s contentions that his acquired psychiatric disorder was caused by an anthrax vaccine while in service. In this regard, the examiner must address the following evidence in the claims file: (i) Anthrax Vaccine: What You Need to Know; (ii) Anthrax Shot Symptoms and Illnesses, Veterans Benefits Network; (iii) Anthrax Vaccine: A Resource for Veterans, Service Members, and their Families, War-related Illness and Injury Study Center, Department of Veterans Affairs. (c) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed acquired psychiatric disorder was caused by the Veteran’s right knee or any other claimed disability? (d) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed acquired psychiatric disorder was aggravated by (increased in severity beyond its natural progression) the Veteran’s right knee or any other claimed disability? Hypertension (a) Is it at least as likely as not (50 percent or greater probability) that hypertension was incurred in or caused by an in-service injury, illness, or event? In responding to the above, the examiner must specifically address the Veteran’s contention that his hypertension was caused by exposure to jet fuel, sewage, mold, asbestos, and/or an anthrax vaccine while in service. In this regard, the examiner must address the following evidence in the claims file: (i) Anthrax Vaccine: What You Need to Know; (ii) Anthrax Shot Symptoms and Illnesses, Veterans Benefits Network; (iii) Anthrax Vaccine: A Resource for Veterans, Service Members, and their Families, War-related Illness and Injury Study Center, Department of Veterans Affairs. (b) Is it at least as likely as not (50 percent or greater probability) that hypertension was caused by the Veteran’s right knee disability, sinus disorder, and/or acquired psychiatric disorder? (c) Is it at least as likely as not (50 percent or greater probability) that hypertension was aggravated by (increased in severity beyond its natural progression) the Veteran’s right knee disability, sinus disorder, and/or acquired psychiatric disorder? Headaches (a) Is it at least as likely as not (50 percent or greater probability) that a headache disorder was incurred in or caused by an in-service injury, illness, or event? In responding to the above, the examiner must specifically address the Veteran’s contention that his headaches were caused by exposure to jet fuel, sewage, mold, asbestos, and/or an anthrax vaccine while in service. In this regard, the examiner must address the following evidence in the claims file: (i) Anthrax Vaccine: What You Need to Know; (ii) Anthrax Shot Symptoms and Illnesses, Veterans Benefits Network; (iii) Anthrax Vaccine: A Resource for Veterans, Service Members, and their Families, War-related Illness and Injury Study Center, Department of Veterans Affairs. (b) Is it at least as likely as not (50 percent or greater probability) that a headache disorder was caused by the Veteran’s sinus disorder, hypertension, and/or an acquired psychiatric disorder? (c) Is it at least as likely as not (50 percent or greater probability) that a headache disorder was aggravated by (increased in severity beyond its natural progression) the Veteran’s sinus disorder, hypertension, and/or an acquired psychiatric disorder? Stomach Disorder, to include GERD (a) Set forth all currently-diagnosed stomach disorders, to include GERD, including those diagnosed during the pendency of the appeal, even if currently resolved. (b) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed stomach disorder was incurred in or caused by an in-service injury, illness, or event? In responding to the above, the examiner must specifically address the Veteran’s contention that his stomach disorder was caused by exposure to jet fuel, sewage, mold, asbestos, and/or an anthrax vaccine while in service. In this regard, the examiner must address the following evidence in the claims file: (i) Anthrax Vaccine: What You Need to Know; (ii) Anthrax Shot Symptoms and Illnesses, Veterans Benefits Network; (iii) Anthrax Vaccine: A Resource for Veterans, Service Members, and their Families, War-related Illness and Injury Study Center, Department of Veterans Affairs. (c) Is it at least as likely as not (50 percent or greater probability) that a stomach disorder was caused by the Veteran’s sinus disorder? (d) Is it at least as likely as not (50 percent or greater probability) that a stomach disorder was aggravated by (increased in severity beyond its natural progression) the Veteran’s sinus disorder? Sleep Apnea (a) Is it at least as likely as not (50 percent or greater probability) that sleep apnea was incurred in or caused by an in-service injury, illness, or event? In responding to the above, the examiner must specifically address the Veteran’s contention that his sleep apnea was caused by exposure to jet fuel, sewage, mold, asbestos, and/or an anthrax vaccine while in service. In this regard, the examiner must address the following evidence in the claims file: (i) Anthrax Vaccine: What You Need to Know; (ii) Anthrax Shot Symptoms and Illnesses, Veterans Benefits Network; (iii) Anthrax Vaccine: A Resource for Veterans, Service Members, and their Families, War-related Illness and Injury Study Center, Department of Veterans Affairs. (b) Is it at least as likely as not (50 percent or greater probability) that sleep apnea was caused by the Veteran’s sinus disorder and/or acquired psychiatric disorder? (c) Is it at least as likely as not (50 percent or greater probability) that sleep apnea was aggravated by (increased in severity beyond its natural progression) the Veteran’s sinus disorder and/or acquired psychiatric disorder? Erectile Dysfunction (a) Is it at least as likely as not (50 percent or greater probability) that erectile dysfunction was incurred in or caused by an in-service injury, illness, or event? In responding to the above, the examiner must specifically address the Veteran’s contention that his erectile dysfunction was caused by exposure to jet fuel, sewage, mold, asbestos, and/or an anthrax vaccine while in service. In this regard, the examiner must address the following evidence in the claims file: (i) Anthrax Vaccine: What You Need to Know; (ii) Anthrax Shot Symptoms and Illnesses, Veterans Benefits Network; (iii) Anthrax Vaccine: A Resource for Veterans, Service Members, and their Families, War-related Illness and Injury Study Center, Department of Veterans Affairs. (b) Is it at least as likely as not (50 percent or greater probability) that erectile dysfunction was caused by the Veteran’s acquired psychiatric disorder? (c) Is it at least as likely as not (50 percent or greater probability) that erectile dysfunction was aggravated by (increased in severity beyond its natural progression) the Veteran’s acquired psychiatric disorder? ---------------------------------------------------------------------Each respective examiner is reminded that the term “at least as likely as not” does not mean “within the realm of possibility.” Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. It is imperative that the examiner’s report reconcile the evidence of record, to include the Veteran’s lay statements, service treatment records, post-service medical records, prior VA examinations and private medical opinions, and any other pertinent lay evidence of record. The examiner is advised that the Veteran is competent to report his medical history, including when his symptoms began, and such reports must be acknowledged and considered in formulating any opinion. The Veteran’s lay contentions must be considered and weighed in making the determination as to whether a nexus exists between the claimed disability and military service. It should be noted that a lack of documented treatment during service for the given disability, while probative, cannot serve as the sole basis for a negative finding. The examiner must provide a complete rationale for any opinion expressed, citing to the examiner’s clinical experience, medical expertise, and established medical principles, as necessary. If the examiner is unable to provide an opinion without resorting to speculation, he or she should fully explain why that is so and what, if any, additional evidence would be necessary before an opinion could be rendered. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Melissa Barbee 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.