Citation Nr: 21003941 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 08-12 315 DATE: January 25, 2021 ORDER An increased rating of 60 percent, but no higher, since August 20, 2009 for Addison’s disease with osteopenia and weight loss is granted. Service connection for swelling of face, hands, feet, legs, and ankles, to include as secondary to service-connected Addison’s disease and medications prescribed for this disability, is denied. REMANDED The issue of service connection for cause of death is remanded. The issue of service connection for hepatitis C is remanded. The issue of service connection for hypogonadism, to include as secondary to service-connected Addison’s disease and medications prescribed for this disability, is remanded. The issue of service connection for weight gain, to include as secondary to service-connected Addison’s disease and medications prescribed for this disability, is remanded. The issue of service connection for joint pain in fingers is remanded. The issue of service connection for generalized muscle weakness is remanded. The issue of service connection for migraines is remanded. The issue of service connection for an eye condition is remanded. The issue of service connection for a sleep disorder is remanded. The issue of service connection for right inguinal herniorrhaphy is remanded. The issue of service connection for small testes is remanded. The issue of service connection for tinnitus is remanded. The issue of a total disability individual unemployability (TDIU) rating is remanded. FINDINGS OF FACT 1. Since August 20, 2009, the Veteran’s Addison’s disease with osteopenia and weight loss manifested with four or more crises during the a one-year period. 2. The preponderance of the evidence of record is against finding that the Veteran had at any time during the appeal, a disability of swelling of face, hands, feet, legs, and ankles. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 60 percent, but no higher, since August 20, 2009 for Addison’s disease with osteopenia and weight loss have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.119, Diagnostic Code (DC) 7911. 2. The criteria to establish service connection for swelling of face, hands, feet, legs, and ankles, to include as secondary to service-connected Addison’s disease and medications prescribed for this disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from February 1984 through May 1986. The appellant is the Veteran’s surviving spouse. In February 2016, the appellant requested to be substituted as the claimant for the purpose of processing the pending claim to completion. See 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010. In a February 2018 notification letter, the RO notified the appellant that her status as the substituted claimant had been recognized and approved. Accordingly, the appellant is substituted. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from December 2006, September 2011, and November 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In August 2009 and October 2019, the Veteran was afforded video conference hearings before the undersigned Veterans Law Judge (VLJ). During the hearings, the VLJ engaged in a colloquy with the Veteran toward substantiation of the claims. Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). A hearing transcript is in the record. The Board remanded the appeal in January 2020 for further development of the record. Specifically, the Board directed the RO to schedule the Veteran for a VA examination to determine whether the Veteran’s swelling of the face, hands, feet, legs, and ankles is evidence of a diagnosed disorder, and if so, whether that diagnosed disorder was caused by the Veteran’s service-connected Addison’s disease, or any afforded medical treatment for such disease. The development was completed. Therefore, the Board finds the directives regarding the issue of swelling of the face, hands, feet, legs, and ankles, having been substantially complied with and the matter again is before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). The remaining issues are discussed in the reasons for remand section. 1. An increased rating in excess of 60 percent, but no higher, since August 20, 2009 for Addison’s disease with osteopenia and weight loss. Disability ratings are determined by applying criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes (DCs). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). Additionally, the evaluation of the same disability under several DCs, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). In assigning a higher disability rating, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran’s chronic Addison’s disease with osteopenia and weight loss was rated as 40 percent disabling under Diagnostic Code (DC) 7911 since March 31, 2005. See 38 C.F.R. § 4.71a, DC 5237. The appellate period is from August 20, 2009, the date VA received the Veteran’s claim for an increased rating. DC 7911 provides ratings for Addison’s disease. A 40 percent rating is warranted for three crises during the past year, or five or more episodes during the past year. A maximum 60 percent rating is warranted for four or more crises during the past year. 38 C.F.R. § 4.119, DC 7911. There are also several relevant note provisions associated with DC 7911. Note (1): An Addisonian “crisis” consists of the rapid onset of peripheral vascular collapse (with acute hypotension and shock), with findings that may include: anorexia; nausea; vomiting; dehydration; profound weakness; pain in abdomen, legs, and back; fever; apathy, and depressed mentation with possible progression to coma, renal shutdown, and death. Note (2): An Addisonian “episode,” for VA purposes, is a less acute and less severe event than an Addisonian crisis and may consist of anorexia, nausea, vomiting, diarrhea, dehydration, weakness, malaise, orthostatic hypotension, or hypoglycemia, but no peripheral vascular collapse. Note (3): Tuberculous Addison’s disease will be evaluated as active or inactive tuberculosis. If inactive, these evaluations are not to be combined with the graduated ratings of 50 percent or 30 percent for non-pulmonary tuberculosis specified under § 4.88b. Assign the higher rating. 38 C.F.R. § 4.119; DC 7911. In the August 2009 Board hearing, the Veteran reported that he was dehydrated, and that he had chronic fatigue and mood swings including irritability and anger. He further reported being hospitalized in 2008 with symptoms of dehydration, vomiting and dizziness; and he was given fluids and steroid replacement. The appellant reported symptoms of agitation, mood swings, and constantly vomiting. In June 2010, the Veteran was afforded a VA examination. The Veteran reported that he gained 100 pounds over the previous three years. He further reported symptoms of polyuria and polydipsia with episodes of dehydration in the previous year that required two hospitalizations for IV drips. He described two Addisonian episodes without circulation collapse. He further reported continuous problems of weakness and fatigability. The Veteran required constant corticosteroid therapy for control of his Addison’s disease symptoms. The Veteran reported symptoms of three headaches per month, vision changes for three years with floating spots and blurry vision, nose bleeds, and ringing in his ear four times per month. In December 2013, the Veteran was afforded another VA examination. The Veteran reported symptoms of nausea, vomiting, weakness, dehydration, fatigue, loss of short-term memory, depression, and mood swings. The Veteran further reported a five-day hospitalization. The examiner indicated that continuous medication was required for control to include dexamethasone, hydrocortisone, and Florinef. There was evidence of corticosteroid therapy required for control, weakness, fatigability, two Addisonian crises in the previous 12 months, and two Addisonian episodes in the previous 12 months. The examiner explained that the Veteran had to be admitted to the hospital for severe fatigue, weakness, nausea, vomiting, dehydration, myopathies, short-term memory loss, hypotension, skin hyperpigmentation, and “tongue.” In a January 2014 letter a private practitioner noted that the Veteran had symptoms of fatigue, lightheadedness upon standing, muscle weakness, fever, weight loss, anxiety, nausea, vomiting, diarrhea, headache, sweating, changes in mood and personality, and joint and muscle pains. The practitioner further noted laboratory abnormalities including hyperkalemia, hyponatremia, hypercalcemia, and hypoglycemia. The practitioner noted that the Veteran required hydrocortisone tablets or prednisone tablets and fludrocortisone. The practitioner indicated that the Veteran’s disease was underrated. VA treatment records and statements from the Veteran and appellant throughout the period on appeal indicate symptoms of hypotension, mood swings, irritability, anger, dyscontrol, rage, weakness, dehydration, diarrhea, lightheaded, dizziness, fatigue, all of which they are competent to describe. Treatment records for the appellate period show emergency room visits due to symptoms of Addison’s disease in April 2012, June 2012, December 2012, and January 2013, which constitute crises. The appellant reported that the Veteran could not eat and could not hold retain foods. She further reported that the Veteran would need to use the bathroom all day and night, which interfered with his ability to sleep. The appellant reported that eventually she would take the Veteran to the hospital and that he was given IVs. The appellant referred to a specific event during the end of 2014/beginning of 2015 where the Veteran could not get up, vomited, and slurred his words. She indicated that the Veteran was taken to the hospital. The appellant’s representative noted that the Veteran’s symptoms were severe and not mild. The appellant has argued that VA was incorrectly missing the number of hospitalizations. Given these facts, the Board finds that a 60 percent rating is warranted for the Veteran’s Addison’s disease with osteopenia and weight loss since August 20, 2009. 38 C.F.R. § 4.7. The evidence specifically shows Addisonian crises resulting in emergency room visits in April 2012, June 2012, December 2012, and January 2013. A 60 percent rating is the maximum schedular rating available for the Veteran’s Addison’s disease with osteopenia and weight loss. 38 C.F.R. § 4.119; DC 7911. 2. Service connection for swelling of face, hands, feet, legs, and ankles, to include as secondary to service-connected Addison’s disease and medications prescribed for this disability. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). “To establish a right to compensation for a present disability, a veteran must show: ‘(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service’ - the so-called ‘nexus’ requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310(a). To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a veteran’s disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). When all the evidence is assembled, the Board is then responsible for determining 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. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The appellant contends that the Veteran had swelling of face, hands, feet, legs, and ankles due to his active service. She alternatively contends that the Veteran had swelling of face, hands, feet, legs, and ankles due to his service-connected Addison’s disease and medications prescribed for such disability. While the appellant believes the Veteran had a diagnosis of swelling of face, hands, feet, legs, and ankles that was caused by his prescribed medications, she is not competent to provide such an opinion in this case. The issue is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). A June 2012 VA examiner opined that it is less likely as not that the Veteran had any swelling of the face, hands, feet, legs, and ankles due to his service-connected disorder to the steroid treatments or any other treatments afforded him for service-connected Addison’s disease. The examiner explained that there was a lack of swelling per the Veteran’s own statement and that there was a lack of significant swelling to the Veteran’s face, hands, feet, legs and ankles during the examination. The examiner further explained that there was a lack of edema noted on several examinations, to include August 2011 Endocrine Note and April 23, 2012 ER Note. The Board has considered Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the Federal Circuit held that “pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability” if it “reaches the level of a functional impairment of earning capacity.” Id. at 1367-69. However, there is no indication that any claimed swelling of the Veteran’s face, hands, feet, legs, and/or ankles had any functional impairment of earning capacity for the Veteran. In a January 2014 private letter, a private practitioner indicated that swelling of the face, hands, feet, and ankles are known side effects of medications used to treat Addison’s disease; however, the practitioner did not opine as to whether the Veteran had a disorder as that term is described by law. The Veteran did not have a disorder separately diagnosed of swelling of face, hands, feet, legs, and ankles, and did not have 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). As the Veteran did not have a current disability, service connection is not warranted. Accordingly, the Veteran’s claim of service connection for swelling of face, hands, feet, legs, and ankles is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND 1. The issue of service connection for cause of death is remanded. 2. The issue of service connection for hepatitis C is remanded. 3. The issue of service connection for hypogonadism, to include as secondary to service-connected Addison’s disease and medications prescribed for this disability, is remanded. 4. The issue of service connection for weight gain, to include as secondary to service-connected Addison’s disease and medications prescribed for this disability, is remanded. 5. The issue of service connection for joint pain in fingers is remanded. 6. The issue of service connection for weakness is remanded. 7. The issue of service connection for migraines is remanded. 8. The issue of service connection for an eye condition is remanded. 9. The issue of service connection for a sleep disorder is remanded. 10. The issue of service connection for right inguinal herniorrhaphy is remanded. 11. The issue of service connection for small testes is remanded. 12. The issue of service connection for tinnitus is remanded. 13. The issue of a TDIU rating is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: The May 2017 VA examiner opined that it was less likely than not that the Veteran’s hypertensive atherosclerotic and valvular cardiovascular disease reported as the Veteran’s primary cause of death was caused by service-connected Addison’s disease, generalized anxiety disorder with mood disorder due to a general medical condition, and/or GERD. However, the examiner did not opine as to whether the Veteran’s hypertensive atherosclerotic and valvular cardiovascular disease were incurred in service or caused by an in-service injury, event, or illness. The September 2014 VA examiner indicated that the Veteran was considered “cured” of hepatitis C and opined that there was no evidence to support that he acquired hepatitis C during active military service or as a result of the treatment he received for his Addison’s disease, but she did not provide a rationale regarding the opinion. To have probative value, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, remand is necessary. The August 2010 VA examination and clarifying February 2011 opinion opined that the Veteran’s hypogonadism was not at least as likely as not due to or caused by the Veteran’s steroid medication. However, the rationale only dealt with the Veteran’s history of hereditary hemochromatosis and did not address causation or aggravation by the Veteran’s service-connected Addison’s disease or medications prescribed for this disease. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). The June 2012 VA examiner indicated that the Veteran did not have weight gain due to the history of weight loss per the Veteran’s own statement, the history of weight loss noted in an August 2010 Endocrine Note, and the history of weight loss recorded from August 2010 through June 2012. However, a January 2014 medical record noted initial weight loss and that the Veteran was gaining it back over a period of 6 months. Furthermore, a June 2010 VA examiner indicated that the Veteran gained 100 pounds over the previous three years. Remand is necessary to obtain an addendum opinion. In March 2007 and January 2012, the Veteran submitted NODs to the December 2006 and September 2011 rating decisions denying service connection for joint pain in fingers, weakness, migraines, an eye condition, a sleep disorder, right inguinal herniorrhaphy, small testes, and tinnitus. Remand is necessary to issue a statement of the case (SOC) regarding these issues. Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). As the TDIU claim is inextricably intertwined with other issues that are being remanded, a remand of this issue is also warranted. 2. Return the file to the examiner who conducted the May 2017 VA examination. If that examiner is no longer available, conduct the following development with a similarly qualified examiner. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. An explanation should be given for all opinions and conclusions rendered. This is a request for clarification by file review. Based upon a review of the relevant evidence of record, history provided by the appellant, and sound medical principles, the VA examiner should provide the following opinion: (a.) Identify whether any of the Veteran’s causes of death, including hypertensive atherosclerotic and valvular cardiovascular disease, were incurred in service or caused by an in-service injury, event, or illness. The examiner must review the entire record in conjunction with rendering the requested opinions. In addition to any records that are generated because of this Remand, the VA examiner’s attention is drawn to the following: • December 1984 Chronological Record of Medical Care indicating a heart with regular rate and rhythm and no murmurs. “STR – Medical,” received August 31, 2009, pages 22 of 92. • February 1985 Narrative Summary (Clinic Resume) indicating that the Veteran had a grade II out of VI systolic ejection murmur heard along the left lower sternal border, heard on admission, but not heard on subsequent examinations. See “STR – Medical,” received July 19, 2005, page 7 of 11. • January 1994 Physical Examination indicating audible first and second heart sound, murmurs at the third and fourth heart sound, and jugular vein distention. See “Medical Treatment Record – Government Facility,” received September 2, 2005, page 38 of 77. • January 1994 Medical Record – Nursing Documentation indicating that the Veteran’s heart skips a beat at night. See “Medical Treatment Record – Government Facility,” received September 2, 2005, page 43 of 77. • March 1994 Medical Certificate indicating no hypertension or cardiac murmur. See “Medical Treatment Record – Government Facility,” received September 2, 2005, page 4 of 77. • January 1995 Medical Record – Nursing Documentation indicating that the Veteran had an irregular heartbeat. See “Medical Treatment Record – Government Facility,” received September 2, 2005, page 43 of 77. • October 2004 and November 2004 Medical Records indicating normal first and second heart sounds, no gallops, and no murmurs. See “Medical Treatment Record – Government Facility,” received September 2, 2005, pages 52 and 64 of 77. • October 2006 Primary Care Unscheduled indicating no murmur. See “Medical Treatment Record – Government Facility,” received December 8, 2006, page 6 of 11. • August 2015 Department of State Health Services Vital Statistics Unit indicating that the Veteran’s cause of death was due to hypertensive atherosclerotic and valvular cardiovascular disease. See “Death certificate,” received July 26, 2016. • May 2017 C&P Examination Note opining that it was less likely than not that the Veteran’s hypertensive atherosclerotic and valvular cardiovascular disease reported as the Veteran’s primary cause of death was caused by service-connected Addison’s disease, generalized anxiety disorder with mood disorder due to a general medical condition, and/or GERD. See “C&P Exam,” received May 12, 2017. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. The examiner is advised that by law, the mere statement that the claims folder was reviewed and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. 3. Return the file to the examiner who conducted the September 2014 VA examination. If that examiner is no longer available, conduct the following development with a similarly qualified examiner. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. An explanation should be given for all opinions and conclusions rendered. This is a request for clarification by file review. Based upon a review of the relevant evidence of record, history provided by the appellant, and sound medical principles, the VA examiner should provide the following opinion: (a.) Identify whether the Veteran’s hepatitis C, even if currently “cured,” was incurred in service or caused by an in-service injury, event, or illness. (b.) Identify whether the Veteran’s hepatitis C, even if currently “cured,” was proximately due to or the result of his service-connected Addison’s disease or his prescribed medications for treatment of such disease. The examiner must review the entire record in conjunction with rendering the requested opinions. In addition to any records that are generated because of this Remand, the VA examiner’s attention is drawn to the following: • April 1985 Medical Record Progress Notes indicating negative hepatitis A and B results. See “STR – Medical,” received August 31, 2009. • March 1994 Medical Record Progress Notes indicating a diagnosis of hepatitis C. See “Medical treatment Record – Government Facility,” received September 2, 2005, page 1 of 75. • October 2004 Infectious Disease Note indicating negative hepatitis A and B results. See “Medical treatment Record – Government Facility,” received August 31, 2009. • March 2007 NOD indicating that the Veteran was tested for hepatitis A and B with negative results due to jaundice and pain and tenderness to his right upper quadrant. The Veteran indicated that he was not tested for hepatitis C. See “NOD,” received March 5, 2007. • April 2008 Appeal to Board of Veterans’ Appeals indicating that hepatitis C has a 30-year incubation period and that the Veteran’s symptoms began to manifest in April 1985 during service. See “Form 9,” received April 18, 2008. • March 2010 article entitled, “HCV Education & Support: A Brief History of Hepatitis C” indicating that it is now believed that approximately 90-95 percent of cases previously classified as non-A, non-B (NA/NB) were actually hepatitis C. See “Correspondence,” received August 28, 2014. • August 2010 C&P Exam Report indicating that the examiner could not resolve the hepatitis C issue without resorting to mere speculation. See “VA Examination,” received August 18, 2010, page 20 of 28. • September 2014 C&P Examination Consult indicating that the Veteran was considered “cured” from hepatitis C and opining that there was no evidence to support that he acquired hepatitis C during active military service or as a result of the treatment he received for his Addison’s disease. See “C&P Exam,” received September 11, 2014. • August 2014 Supplement indicating that the Veteran’s hepatitis C diagnosis is based upon the disease’s progression and chronicity, with the confirmation of hepatitis C, and diagnosis of cirrhosis of the liver approximately 30 years after the Veteran’s in-service treatment records documenting elevated liver function, which are consistent with hepatitis C during military service. Furthermore, noting that while testing for hepatitis A and B were negative, nonetheless, this may have represented a condition known as non-A and non-B hepatitis, which later was renamed hepatitis C. See “NOD,” received August 28, 2014 pages 6 and 14 of 31. • January 2014 letter opining that it is as likely as that the medically documented symptoms during service were those of hepatitis C. See “Medical Treatment record – Non-Government Facility,” received August 28, 2014. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. The examiner is advised that by law, the mere statement that the claims folder was reviewed and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. 4. Return the file to the examiner who conducted the August 2010 VA examination. If that examiner is no longer available, conduct the following development with a similarly qualified examiner. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. An explanation should be given for all opinions and conclusions rendered. This is a request for clarification by file review. Based upon a review of the relevant evidence of record, history provided by the appellant, and sound medical principles, the VA examiner should provide the following opinion: (a.) Identify whether the Veteran’s hypogonadism was incurred in service or caused by an in-service injury, event, or illness. (b.) Identify whether the Veteran’s hypogonadism was proximately due to or the result of his service-connected Addison’s disease or his prescribed medications for treatment of such disease. The examiner must review the entire record in conjunction with rendering the requested opinions. In addition to any records that are generated because of this Remand, the VA examiner’s attention is drawn to the following: • March 2006 C&P Endocrine Diseases indicating that the Veteran’s hypogonadism was treated and was possibly due to his hemochromatosis. See “VA Examination,” received March 31, 2006. • August 2010 C&P Endocrine Diseases indicating that the Veteran’s central hypogonadism was likely secondary to hemochromatosis with deposition of ferratin in pituitary. See “VA Examination,” received August 18, 2010, page 9 of 38. • August 2010 e-mail correspondence indicting that central hypogonadism was likely secondary to hemochromatosis with deposition of ferratin in pituitary and that it was not caused by or result of the Veteran’s service-connected Addison’s disease. See “Email Correspondence,” received November 18, 2010. • February 2011 e-mail correspondence indicating that central hypogonadism was likely secondary to hemochromatosis with deposition of ferratin in pituitary, that the opinion was based on two different expertise endocrinologist’s notes, and that hypogonadism was not at least as likely as not due to or caused by the steroid medication. See “Email Correspondence,” received February 15, 2011. • August 2014 letter from a private practitioner opining that the Veteran’s hypogonadism/decreased libido was likely as not secondary to his Addison’s disease because it was medically reasonable to attribute his decreased libido to the side effects of treatment of Addison’s disease. See “Medical Treatment Record – Non-Government Facility,” received August 28, 2014. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. The examiner is advised that by law, the mere statement that the claims folder was reviewed and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. 5. Return the file to the examiner who conducted the June 2012 VA examination. If that examiner is no longer available, conduct the following development with a similarly qualified examiner. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. An explanation should be given for all opinions and conclusions rendered. This is a request for clarification by file review. Based upon a review of the relevant evidence of record, history provided by the appellant, and sound medical principles, the VA examiner should provide the following opinion: (a.) Identify whether the Veteran’s weight gain was incurred in service or caused by an in-service injury, event, or illness. (b.) Identify whether the Veteran’s weight gain was proximately due to or the result of his service-connected Addison’s disease or his prescribed medications for treatment of such disease. The examiner must review the entire record in conjunction with rendering the requested opinions. In addition to any records that are generated because of this Remand, the VA examiner’s attention is drawn to the following: • April 2008 Endocrinology Note indicating that the Veteran gained 101 pounds over the previous four months. See “Medical Treatment Record – Government Facility,” received May 1, 2008, page 1 of 20. • June 2010 C&P Examination indicating that the Veteran gained 100 pounds over the previous three years. See “C&P Exam,” received August 10, 2010. • October 2009 Mental Health Outpatient Note and September 2010 Sleep Medicine Note indicating the Veteran’s report of weight gain over the previous four to five years began after he started on steroids for adrenal insufficiency. See “CAPRI,” received August 28, 2014, pages 88 and 94 through 117. • June 2012 Internal Medicine C&P Examination Consult indicating that the Veteran did not have weight gain due to the history of weight loss per the Veteran’s own statement, the history of weight loss noted in an August 2010 Endocrine Note, and the history of weight loss recorded from August 2010 through June 2012. See “VA Examination,” received June 15, 2002, page 26 of 66. • January 2014 Gastroenterology Consult indicating that the Veteran initially lost weight and then began gaining it back over the previous 6 months. See “CAPRI,” received February 7, 2014, page 5 of 507. • January 2014 letter from private practitioner indicating that it would be medically reasonable to attribute his weight gain to side effects of treatment of Addison’s disease. See “Medical Treatment Record – Non-Government Facility,” received August 28, 2014. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. The examiner is advised that by law, the mere statement that the claims folder was reviewed and/or the examiner has expertise is not sufficient to find the examination/opinion sufficient. 6. The Agency of Original Jurisdiction (AOJ) should issue a SOC addressing the issues of service connection for joint pain in fingers, weakness, migraines, an eye condition, a sleep disorder, right inguinal herniorrhaphy, small testes, and tinnitus. The appellant should be given an opportunity to perfect an appeal by submitting a timely substantive appeal in response thereto. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. McLendon, 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.