Citation Nr: 21062089 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 18-16 046 DATE: October 6, 2021 ORDER A compensable rating for bilateral hearing loss is denied. Entitlement to service connection for an acquired psychiatric disorder is granted. Entitlement to service connection for sinusitis and allergic rhinitis is granted. Entitlement to service connection for sleep apnea is granted. REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for hiatal hernia is remanded. Entitlement to service connection for a prostate condition is remanded. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran had, at worst, Level VI hearing acuity of his right ear and Level I hearing acuity of his left ear. 2. An acquired psychiatric disorder, to include PTSD and major depressive disorder, is related to service. 3. The Veteran was exposed to contaminated drinking water at Camp Lejeune. 4. Sinusitis and allergic rhinitis are related to the Veteran's exposure to contaminated water in service. 5. Obstructive sleep apnea is proximately due to the Veteran's service-connected sinusitis and allergic rhinitis. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.85, 4.86, Part 4, Diagnostic Code (DC) 6100. 2. The criteria for service connection for an acquired psychiatric disorder, diagnosed as PTSD and major depressive disorder, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for service connection for sinusitis and allergic rhinitis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for obstructive sleep apnea secondary to service-connected sinusitis and allergic rhinitis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1966 to April 1969. The Board previously remanded this matter in July 2017 and October 2018. 1. Increased rating for bilateral hearing loss The Rating Schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on puretone thresholds and controlled speech discrimination (Maryland CNC) testing. Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment of each ear. 38 C.F.R. § 4.85. The "puretone threshold average" as used in Table VI is the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. This average is used in all cases to determine the Roman numeral designation for hearing impairment from Table VI or Via. 38 C.F.R. § 4.85 (d). Ratings for hearing impairment are derived by the mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345 (1992). The Rating Schedule provides a table (Table VI) to determine a Roman numeral designation (I through XI) for hearing impairment, based on puretone thresholds and controlled speech discrimination (Maryland CNC) testing. Table VII is used to determine the rating assigned by combining the Roman numeral designations for hearing impairment of each ear. 38 C.F.R. § 4.85. Where there is an exceptional pattern of hearing impairment as defined in 38 C.F.R. § 4.86, the rating may be based solely on puretone threshold testing. An exceptional pattern of hearing impairment occurs when the puretone thresholds in each of the four frequencies 1000, 2000, 3000, and 4000 Hertz are 55 decibels or greater, or when the puretone threshold at 1000 Hertz is 30 decibels or less and the threshold at 2000 Hertz is 70 decibels or more. 38 C.F.R. § 4.86 (a), (b). A September 2005 rating decision granted service connection for right ear hearing loss. The current claim for an increased rating was received in July 2015. A March 2016 rating decision continued a non-compensable (0 percent) rating for right ear hearing loss Subsequent to the March 2016 rating decision, an October 2018 Board decision granted service connection for left ear hearing loss. As such, the Veteran is now service-connected for bilateral hearing loss from July 30, 2015. Although the issue of left ear hearing loss was not appealed as part of the rating decision on appeal, the issue is now before the Board because the Board must consider the hearing impairment in both ears to assign an appropriate rating. VA audiometric examination in February 2015 showed puretone thresholds of 70, 70, 75, and 75 at frequencies of 1000, 2000, 3000, and 4000 Hertz for the right ear. The examination showed puretone thresholds of 35, 35, 35, and 40 at frequencies of 1000, 2000, 3000, and 4000 Hertz in the left ear. The average puretone thresholds were 73 for the right ear and 36 for the left ear. The Veteran had speech discrimination of 100 percent in both ears. According to Table VI, based on those values, a numeric designation of I is assigned for the left ear and II for the right ear. The Veteran had an exceptional pattern of hearing impairment in the right ear, so the Board must also consider the application of Table VIa. Using Table VIa, a numeric designation of VI is assigned for the right ear. The functional impact was having to ask for repetition frequently and having problems following group conversation and hearing if there was background noise present. The Veteran also reported that his wife complained because he turned the television volume up too high. VA audiometric examination in March 2016 showed puretone thresholds of 75, 60, 75, and 70 at frequencies of 1000, 2000, 3000, and 4000 Hertz for the right ear. The examination noted puretone thresholds of 35, 25, 25, and 30 at frequencies of 1000, 2000, 3000, and 4000 Hertz for the left ear. The average puretone thresholds were 70 for the right ear and 29 for the left ear. Speech discrimination for the right ear was 100 percent. These values correspond to a numeric designation of II for the right ear. A numeric designation of I is assigned for the left ear. There was an exceptional pattern of hearing impairment of the right ear, so the Board must consider the application of Table VIa. According to Table VIa, a numeric designation of VI is assigned for the right ear. The functional impact was difficulty understanding conversations and TV. VA audiometric examination in October 2017 showed puretone thresholds of 65, 50, 70, and 70 at frequencies of 1000, 2000, 3000, and 4000 Hertz for the right ear. The examination showed puretone thresholds of 35, 15, 25, and 35 at frequencies of 1000, 2000, 3000, and 4000 Hertz for the left ear. The average of the four frequencies was 64 for the right ear and 28 for the left ear. Speech discrimination was 96 percent for the right ear and 100 percent for the left ear. These values correspond to a numeric designation of II for the right ear and I for the left ear. The functional impact was difficulties following a conversation, understanding the TV, and talking on the phone. VA audiometric examination in August 2020 showed puretone thresholds of 70, 65, 75, and 75 at frequencies of 1000, 2000, 3000, and 4000 Hertz for the right ear. The examination noted puretone thresholds of 30, 25, 20, and 35 at frequencies of 1000, 2000, 3000, and 4000 Hertz for the left ear. The average of the four frequencies was 71.25 for the right ear and 27.5 for the left ear. Speech discrimination was 94 percent for the right ear and 96 percent for the left ear. These values correspond to numeric designations of II for the right ear and I for the left ear. There was an exceptional pattern of hearing impairment of the right ear, so the Board must consider the application of Table VIa. According to Table VIa, a numeric designation of VI is assigned for the right ear. The reported functional impact was difficulty hearing and understanding speech. The Board finds that the criteria for a compensable rating were not met during the entire appeal period. The evidence reflects that the Veteran had no worse than Level VI hearing of the right ear and Level I hearing acuity of the left ear, as shown on VA examinations dated in February 2015, March 2016, and August 2020, and no worse than Level II hearing of the right ear and Level I hearing of the left ear shown on October 2017 VA examination. Therefore, the level of hearing acuity from warrants a non-compensable rating. As the preponderance of the evidence is against the claim for a compensable rating for bilateral hearing loss for the entire appeal period, the claim must be denied. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of 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 present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When aggravation of a Veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen, supra. Service connection may be established on a presumptive basis for certain disabilities resulting from exposure to an herbicide agent. A Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 C.F.R. § 3.307 (a)(6)(iii). Personnel records show that the Veteran served in the Republic of Vietnam, and he is therefore presumed to have been exposed to herbicides. However, sleep apnea, sinusitis, and allergic rhinitis are not included among the presumptive conditions. Notwithstanding the provisions relating to presumptive service connection, a Veteran may establish service connection for a disability with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). A Veteran who had no less than 30 days of service at Camp Lejeune during the period beginning on August 1, 1953 and ending on December 31, 1987, is presumed to have been exposed during such service to the following contaminants in the water supply at Camp Lejeune: trichloroethylene (TCE), perchloroethylene (PCE), benzene and vinyl chloride. 38 C.F.R. § 3.307. Personnel records show that the Veteran was stationed at Camp Lejeune from July 1968 to March 1969. The Veteran is therefore presumed to have been exposed to contaminants in the water at Camp Lejeune during service. 2. Entitlement to service connection for an acquired psychiatric disorder The Veteran seeks service connection for PTSD, claimed as due to combat incidents during his service in Vietnam. In a September 2014 statement, the Veteran reported seeing people killed and wounded. His VA examinations show that he reported participating in the TET offensive and seeing many dead soldiers. Service connection for PTSD generally requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. See 38 C.F.R. § 3.304 (f). See also Cohen v. Brown, 10 Vet. App. 128 (1997). Personnel records reflect that the Veteran served in Vietnam from April 1967 to March 1968. During this period, he participated in operation Beavercage, Hickory, Bear Bite, and Colgate, as well as counter-insurgency operations against the Viet Cong. The Board finds that the Veteran's reported stressors of seeing people killed and wounded in Vietnam is consistent with the circumstances of his service. 38 U.S.C. § 1154(a). A private treatment record from Dr. N.V., dated in 2013 noted that the Veteran experienced excessive anxiety and worry since being in a combat zone. The Veteran had a VA examination in September 2014. The examiner opined that the Veteran does not have a diagnosis that conforms to DSM-5 criteria. The examiner opined that there was no evidence of a mental disorder. A September 2015 medical opinion from a private physician, Dr. C.Q., reflects a diagnosis of PTSD. In July 2017, the Board remanded the acquired psychiatric disorder claim for a VA examination. In August 2017, a VA examiner opined that the Veteran's stressors meet the criteria for fear of hostile military activity. The examiner opined that there was no evidence of a mental disorder since October 2013 and no evidence of PTSD or any other mental disorder as per DSM-5. The examiner considered the 2013 and 2015 medical opinions diagnosing anxiety symptoms and PTSD. The examiner indicated that those opinions were not considered pertinent because the practices of those physicians were outside the scope of psychiatry. An addendum opinion was obtained in January 2018. The examiner was asked to clarify the finding on the August 2017 examination that the Veteran's stressors were adequate to support a diagnosis of PTSD. The examiner opined that meeting the criteria for a stressor for PTSD is one of the criteria for its diagnosis. The examiner stated that all of the criteria must be met for a diagnosis to be assigned. VA treatment records dated in October 2019 reflect that the Veteran was diagnosed with delayed onset PTSD, adjustment disorder, and major depressive disorder. The diagnosis was rendered by a VA psychologist. The Veteran had a VA examination in December 2020. The examiner diagnosed depressive disorder. The examiner opined that it is not related to military service. The examiner noted that the Veteran began psychiatric treatment in 2018. The examiner did not address the records showing that VA treatment providers diagnosed the Veteran with PTSD. The September 2014, August 2017, January 2018, and December 2020 medical opinions did not address the VA treatment records showing that the Veteran was diagnosed with PTSD, and therefore they are afforded low probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is a credible stressor, and a VA psychologist diagnosed PTSD according to DSM-5 criteria. The diagnosis is linked to service, as it was based on his exposure to stressors in combat. Further, the PTSD diagnosis is presumed to be made in accordance with 38 C.F.R. § 4.125 (a). See Cohen, supra. at 140 (finding that mental health professionals making a PTSD diagnosis "are presumed to know the DSM requirements applicable to their practice and to have taken them into account in providing a PTSD diagnosis."). Service connection for an acquired psychiatric disorder, variously diagnosed as PTSD, adjustment disorder, and major depressive disorder, is warranted. 3. Entitlement to service connection for a respiratory disorder, including sinusitis, rhinitis, and sleep apnea The Veteran claims service connection for a respiratory disorder, to include as due to Agent Orange exposure and contaminated water at Camp Lejeune. Alternatively, he contends that a respiratory disorder is related to his service-connected chronic suppurative mastoiditis of the right ear status post radical mastoidectomy and chronic otitis media. VA treatment records reflect that the Veteran has current diagnoses of sinusitis and rhinitis and sleep apnea. See January 2021 VA examination. As noted previously, the Veteran is presumed to have been exposed to Agent Orange in Vietnam. In addition, he was exposed to contaminated water at Camp Lejeune. Therefore, the requirement of an in-service injury is met. The remaining question is whether there is a nexus between his current disabilities and his exposure to Agent Orange and/or contaminated water. The record contains several medical opinions addressing the etiology of his diagnosed respiratory disorders. A September 2013 private treatment record noted a history of respiratory problems but did not show a specific diagnosis. The physician opined that the Veteran's respiratory problems are at least as likely as not related to the Veteran's service-connected ear and nose surgery. VA treatment records dated in March 2017 reflected a diagnosis of acute respiratory infection. The Veteran had a VA examination in August 2017. The examiner opined that, after reviewing the file, chart, and medical literature and an interview with the Veteran, the Veteran's acute respiratory tract infection is less likely than not incurred in or caused by service or aggravated by chronic suppurative mastoiditis, right, post radical mastoidectomy, and chronic otitis media. The examiner explained that service treatment records are silent for a diagnosis of sinusitis during service, and there is no evidence of any manifestation or diagnosis of chronic sinusitis within a year after separation from active service. The examiner opined that obstructive sleep apnea is less likely than not incurred in or caused by service or aggravated by chronic suppurative mastoiditis, right, post radical mastoidectomy. The examiner's rationale was that service treatment records are silent for any diagnosis of symptoms of obstructive sleep apnea, and there was no evidence of any manifestation or diagnosis of obstructive sleep apnea within a year of separation from service. In November 2020, a VA examiner opined that the Veteran did not have any respiratory conditions. As no respiratory conditions were found on examination, the examiner did not offer a medical opinion. Another VA medical opinion was obtained in December 2020. The examiner diagnosed chronic sinusitis, allergic rhinitis, deviated nasal septum (traumatic), and obstructive sleep apnea. The examiner noted that the Veteran reported the onset of nasal symptoms while in Vietnam. He also had facial trauma from an explosion with facial injuries from shrapnel. The examiner opined that the clamed injuries are at least as likely as not due to the claimed in-service injury, event, or illness. The examiner's rationale was that known causes of respiratory disorders are exposure to environmental hazards, exposure to chemicals, and contact with contaminated water. The examiner noted that the Veteran had exposure to all of the above and facial trauma from explosion. The examiner opined that, therefore, the claimed obstructive sleep apnea, respiratory disorder, and/ or sinusitis are at least as likely as not related to his active service, including exposure to Agent Orange and exposure to water at Camp Lejeune. Another VA medical opinion was obtained in April 2021. The examiner concurred with the positive December 2020 opinion. The examiner indicated that there was no evidence of respiratory conditions on examination. The STRs showed that the Veteran had an upper respiratory illness while he was hospitalized at Camp Lejeune in December 1968. The upper respiratory illness described in the STR refers to the upper respiratory tract that includes the nose and throat, but it was not involving the lungs. The respiratory illness was an acute, likely infectious, ENT condition that was transitory and resolved within the admission. The examiner opined that the current allergic rhinitis and chronic sinusitis were at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness, including exposure to contaminated water at Camp Lejeune. The examiner concurred with the December 2020 opinion, which related the Veteran's rhinitis and sinusitis to exposure to contaminated water at Camp Lejeune. The examiner further explained that there is evidence in medical literature that environmental exposure to hazardous materials precipitate allergic rhinitis and sinusitis symptoms in sensitive patients. The examiner opined that the current obstructive sleep apnea is at least as likely as not proximately due or the result of the Veteran's allergic rhinitis and chronic sinusitis. The examiner's rationale was that the medical literature review does support that chronic persistent nasal congestion by rhinitis and sinusitis confers an approximately two-fold increase in the prevalence of OSA, regardless of the cause of nasal congestion, probably related to increased resistance due to decreased nasal patency. In May 2021, a VA physician completed an addendum opinion. The examiner opined that the current allergic rhinitis and sinusitis at least as likely as not had their onset or are otherwise related to exposure to contaminated water at Camp Lejeune. The examiner opined that obstructive sleep apnea is at least as likely as not secondary to allergic rhinitis and sinusitis. The examiner's rationale was that medical literature supports that chronic persistent nasal congestion by rhinitis and sinusitis confers an approximately two-fold increase in the prevalence of OSA, regardless of the cause of nasal congestion, probably related to an increased resistance due to decreased nasal patency. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current allergic rhinitis and sinusitis are related to exposure to contaminated water exposure at Camp Lejeune. The Board finds that the Veteran's obstructive sleep apnea is proximately due to allergic rhinitis and sinusitis. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection is warranted for allergic rhinitis, sinusitis, and obstructive sleep apnea. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 4. Entitlement to service connection for a back disability is remanded. The Veteran contends that his back disability is related to service. In October 2018, the Board remanded the claim for a VA examination. The Veteran had a VA examination in December 2020. The examiner diagnosed degenerative arthritis of the spine. The examiner opined that the condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. There was no evidence of any back complaints, diagnosis, treatments, or radiological evidence of any back conditions during service or a year thereafter. The examiner opined that Agent Orange is not related to lumbar spondylosis (no evidence in medical literature). The examiner noted that actual spondylosis is most likely due to aging. The examiner's opinion was based partly on a lack of a documented complaint of a back disability in service. The examination did not address the reported history of back symptoms. The absence of treatment in service is not a permissible basis for a negative nexus opinion. In addition, as the Veteran engaged in combat operations during service in Vietnam, the Veteran's lay statements about his back injuries and symptoms in service are sufficient to establish in-service incurrence of a back injury. The examination did not fully describe the history of the Veteran's back symptoms and did not consider the competent lay evidence. The Board finds that a remand for a new examination is necessary. 5. Entitlement to service connection for hiatal hernia is remanded. The Veteran claims entitlement to service connection for a hiatal hernia, to include as due to Agent Orange exposure. VA treatment records dated in June 2018 noted that the side effects of psychotropic drugs include gastrointestinal distress. The issue of secondary service connection due to his service-connected acquired psychiatric disorder is raised by the record. The Veteran was afforded a VA examination in November 2020. The examiner opined that the claimed condition of GERD was less likely than not related to active service, including exposure to Agent Orange. The examiner's rationale was that hiatal hernia with GERD is not included in the list of presumptive conditions associated with Agent Orange exposure. The Board finds this opinion concerning herbicide exposure to be inadequate as it did not address whether direct service connection based on in-service herbicide agent exposure was warranted regardless of hiatal hernia with GERD not being a presumptive disability. A remand for an addendum opinion is necessary The case is being remanded for an addendum opinion addressing whether his hiatal hernia is caused or aggravated by his service-connected psychiatric disorder or his exposure to Agent Orange. 6. Entitlement to service connection for a prostate condition is remanded. The Veteran seeks service connection for a prostate condition, to include due to Agent Orange exposure. The Veteran had a VA examination in December 2020. The examiner diagnosed benign prostatic hypertrophy (BPH). The examiner opined that BPH less likely than not had (its) onset in service or is etiologically related to service, including exposure to Agent Orange. The examiner's rationale was that there was no diagnosis of BPH during service or within one year of separation. The examiner noted that BPH is not on the list of conditions associated with Agent Orange exposure. The Board finds this opinion concerning herbicide exposure to be inadequate as it did not address whether service connection based on in-service herbicide agent exposure was warranted regardless of BPH not being a presumptive disability. A remand for an addendum opinion is necessary. 7. Entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) is remanded. The Veteran contends that he is unable to work due to his service-connected PTSD, hearing loss, and heart condition. In June 2021, a VA examiner opined that the Veteran could perform sedentary work. The Veteran does not meet the schedular criteria for TDIU. In this decision, the Board has granted service connection for the Veteran's acquired psychiatric disability, as well as sinusitis, rhinitis, and sleep apnea, but neither a disability rating nor an effective date have been assessed by the RO. Moreover, the claims of service connection for a back disability, hiatal hernia, and prostate condition are being remanded for additional development. As a claim of entitlement to TDIU is based on an analysis of the schedular rating of all of the Veteran's service-connected disabilities, the issue of entitlement to TDIU is remanded as potentially intertwined with the assignments of disability ratings and effective dates for an acquired psychiatric disability, to include PTSD and major depressive disorder, sinusitis, rhinitis, and sleep apnea, and the remands of the back disability, hiatal hernia, and prostate condition. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his back disability. The examiner must review the claims file. The examiner must provide an opinion as to whether the Veteran's back disability is at least as likely as not related to service, including consideration of combat operations in Vietnam. The examiner must provide a description of the history of the Veteran's back disability symptoms. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. The examiner should provide a rationale to support the opinion. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's hiatal hernia. The examiner must address the following questions: (a) Whether the Veteran's hiatal hernia is at least as likely as not related to his exposure to Agent Orange in service. (b) Whether hiatal hernia is proximately due to service-connected PTSD, including medications for PTSD (c) Whether hiatal hernia is at least as likely as not aggravated beyond its natural progression by service-connected PTSD, including medications for PTSD. The examiner should provide a rationale to support the opinion. The examiner is advised that the sole basis for a negative opinion may not be the fact that hiatal hernia with GERD is not presumptively associated with herbicide agent exposure under VA regulations. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's prostate disability. The examiner must address whether BPH is at least as likely as not related to Agent Orange exposure in service. The examiner should provide a rationale to support the opinion. The examiner is advised that the sole basis for a negative opinion may not be the fact that BPH is not presumptively associated with herbicide agent exposure under VA regulations. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Catherine Cykowski 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.