Citation Nr: 21064709 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 20-30 119 DATE: October 21, 2021 ORDER New and material evidence having been received, the petition to reopen the claim for service connection for arthritis of the hands is granted. Service connection for rheumatoid arthritis of bilateral hands, including as due to exposure to contaminated water at Camp Lejeune and as due to exposure to herbicide agents including Agent Orange, is denied. REMANDED Entitlement to service connection for osteoarthritis of bilateral hands, including as due to exposure to contaminated water at Camp Lejeune and as due to exposure to herbicide agents including Agent Orange, is remanded. Entitlement to service connection for neurobehavioral effects, including as due to exposure to contaminated water at Camp Lejeune and as due to exposure to herbicide agents including Agent Orange, is remanded. FINDINGS OF FACT 1. Evidence received since the last denial of service connection for arthritis of the hands is new and material, and raises a reasonable possibility of substantiating the claim. 2. The weight of the probative evidence does not support a finding that the Veteran's rheumatoid arthritis of the hands resulted from a disease or injury incurred in service, including exposure to herbicide agents including Agent Orange, or toxic chemicals in the drinking water at Camp Lejeune. CONCLUSIONS OF LAW 1. The Board's April 2009 decision constitutes a final decision; new and material evidence has been received to reopen the claim of entitlement to service connection for arthritis. 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. 2. The criteria for service connection for rheumatoid arthritis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from June 1965 to September 1974. This appeal comes before the Board of Veterans' Appeals (Board) from a June 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran did not request a hearing for the issues discussed in this document. See 9/15/2020 Form 9. However, VA records show that Veteran requested a hearing on other issues (see 8/23/2019 Form 9) appeared before another Veterans Law Judge (VLJ) in September 2021. Those issues will be the subject of a separate Board decision by the VLJ who held that hearing. 1. New and material evidence having been received, the petition to reopen the claim for service connection for arthritis of the hands is granted. The Board is required to address petitions to reopen previously denied claims on the basis of new and material evidence in the first instance. The Board has the jurisdiction to address a new and material issue and to reach the underlying de novo claims. If the Board determines that new and material evidence has not been received, the adjudication of the particular claim ends, and further analysis is neither required nor permitted. Any decision that the Agency of Original Jurisdiction (AOJ) may have made with regard to a new and material claim is irrelevant. Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). Thus, the Board will proceed in the following decision to adjudicate this new and material issue in the first instance. New evidence is defined as existing evidence not previously submitted to VA. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Shade, 24 Vet. App. at 118. Additionally, the United States Court of Appeals for the Federal Circuit has noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). Only evidence presented since the last, final denial on any basis (either upon the merits of the case, or upon a previous adjudication that no new and material evidence has been presented) will be evaluated in the context of the entire record. Evans v. Brown, 9 Vet. App. 273, 284 (1996). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, VA is not bound to consider credible the patently incredible. Duran v. Brown, 7 Vet. App. 216 (1994). In April 2009, the Board denied the Veteran's claim for service connection for arthritis of bilateral hands. The Board's decision referenced prior diagnoses and treatment for both osteoarthritis and rheumatoid arthritis, in its generalized discussion of the claim for "arthritis." It found that arthritis of the hands was not affirmatively shown to have had onset during service, did not manifest to a compensable degree within a year of separation and was not related to service. The Veteran did not appeal or challenge the 2009 Board decision so it became final. 38 U.S.C. § 7104; 38 C.F.R. § 20.1100. Since April 2009, VA has received new evidence in support of the Veteran's claims for osteoarthritis and rheumatoid arthritis, including lay statements from the Veteran and his family members, updated medical records, internet and academic journal publications, and letters from the Veteran's private treating physician. This evidence is new in that it has not been previously considered by VA, and it is material in that it tends to prove or disprove elements of the Veteran's several theories of service connection, as well providing a more complete picture of the circumstances surrounding the origin of the Veteran's disabilities. See Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). Accordingly, the Board finds the "low" threshold has been met, and the petition to reopen the claims for service connection for osteoarthritis and rheumatoid arthritis (now claimed separately) is granted. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). 2. Entitlement to service connection for rheumatoid arthritis of bilateral hands, including as due to exposure to contaminated water at Camp Lejeune and as due to exposure to herbicide agents including Agent Orange, is denied. The Veteran seeks service connection for rheumatoid arthritis of his hands. He has argued that his rheumatoid arthritis condition could be the result of in-service injury, or the result of in-service exposure to contaminated water at Camp Lejeune, or the result of in-service exposure to herbicide agents including Agent Orange during his service in Vietnam. The Board will first address whether presumptive service connection may be granted due to exposure to contaminated water at Camp Lejeune or due to exposure to Agent Orange in Vietnam. Veterans exposed to Agent Orange or other listed herbicide agents are presumed service-connected for certain medical conditions even if there is no record of such disease during service. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). VA regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period from January 9, 1962 to 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 U.S.C. § 1116; 38 C.F.R. § 4.407(a)(6)(iii). The Veteran's service in Vietnam has previously been established by VA, and thus the Veteran is presumed to have been exposed to Agent Orange while on active duty. However, rheumatoid arthritis is not among the conditions listed in 38 C.F.R. § 3.309(e) which warrant presumptive service connection based on such exposure. Similarly, presumptive service connection may be granted for Veterans who were exposed to contaminants in the water supply at Camp Lejeune during the period beginning on August 1, 1953 and ending on December 31, 1987. The Veteran is shown to have served at Camp Lejeune for 30 days or more during that period, and thus he is entitled to presumptive service connection for certain diseases listed in 38 C.F.R. § 3.309(f). However, rheumatoid arthritis is not among the conditions listed in 38 C.F.R. § 3.309(f), and therefore service connection may not be granted on a presumptive basis. Even though the Veteran's condition does not meet the requirements for presumptive service connection under either of these statutes, he may still establish service connection on a direct basis. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). However, regarding the Veteran's presumed exposure to Agent Orange and other herbicide agents in Vietnam, the Board observes no medical or lay evidence of record has linked, or sought to link, the Veteran's rheumatoid arthritis to Agent Orange exposure. Although the Veteran has argued his rheumatoid arthritis might have been caused by Agent Orange, the competent evidence of record does not tend to support such an assertion. Similarly, no VA examiner has addressed such assertion. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, four factors are for consideration: (1) competent evidence of a current disability or recurrent symptoms; (2) establishment of an in-service event, injury, or disease; (3) indication that the current disability may be associated with an in-service event; and (4) sufficient competent medical evidence to decide the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-85 (2006). Here, the Board does not find a VA examination or opinion is necessary to address Agent Orange or other herbicide agents. The evidence does not indicate that the Veteran's hand condition is associated with Agent Orange in any way. Therefore, the Board concludes that a decision may be reached based upon the evidence of record. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must generally be 1) 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) causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The record shows a diagnosis of rheumatoid arthritis in bilateral hands, with a history of treatment dating to as early as March 1991. See November 2003 Medical Treatment Record Non-Government Facility, p.5 (February 2003 record). Thus, the first Shedden prong is met. Although presumptive service connection may not be granted either under Agent Orange provisions or provisions for contaminated water at Camp Lejeune, the Veteran is still presumed to have been exposed to chemicals in both those instances. Such chemical exposures constitute an in-service event, and thus the second Shedden prong is met. Additionally, the Veteran has stated that he experienced pain in his hands during his military service, and service treatment records show two instances in which the Veteran was treated for a hand complaint or injury. In January 1968, the Veteran lacerated his right index finger; the Veteran has described that this was due to a pallet being accidentally lowered on both his hands while loading a vehicle. See July 2003 VA Form 9. Although the service records only show treatment for a cut on the right index finger, the Veteran has stated that doctors focused on his right hand because it was more swollen than his left. See August 2005 VA Form 9. Later that year, in July 1968, the record shows the Veteran complained of pain in the radial aspect of his right hand for five days. See January and July 1968 records in August 2014 Service Treatment Record Medical. Additionally, the Veteran has described having cramped and swollen hands and fingers due to his work as a keypunch technician during service. See January 2008 correspondence. The Veteran has stated that for his painful hands, he sought treatment at sickbay numerous times during service, where he was seen by a corpsman but not a doctor. See November 2007 Hearing Testimony (Decision Review Officer Hearing). Service Treatment records do not show such repeated trips to sick call. Nonetheless, resolving reasonable doubt in the Veteran's favor, the second Shedden prong of an in-service incident is established on each of these bases. The third Shedden prong requires a nexus, or a link, between the present disabling condition and the in-service injury, disease or incurrence. To this point, the Board finds conflicting evidence of record. In March 2007, the Veteran underwent a VA examination of his hands. The examiner identified that the Veteran had a possible rheumatoid nodule present on his right fourth metacarpal. However, the examiner did not diagnose rheumatoid arthritis, nor did the examiner otherwise discuss rheumatoid arthritis at that time. See March 2007 VA Examination. In August 2008, the Veteran underwent another VA examination for hand arthritis. The report shows consideration of the Veteran's reports of being diagnosed with rheumatoid hand arthritis and it existing since 1968. It stated that the VA established diagnosis of hand arthritis had progressed to bilateral hand rheumatoid arthritis and degenerative joint disease. The examiner only offered opinions on degenerative arthritis. See August 2008 VA Examination. In October 2008, VA obtained an independent medical opinion based upon a review of the Veteran's medical records by a private physician. That doctor wrote that the Veteran had diagnoses of both osteoarthritis and rheumatoid arthritis, but she was unable to distinguish which condition was predominantly the cause of his symptoms. She wrote an opinion that it was less likely than not that the Veteran's rheumatoid arthritis was related to either of the medical events shown during service in January and July 1968. The Veteran's service records did not show documentation of a persistent, chronic hand condition during service. Yet the American Rheumatological Association's criteria for rheumatoid arthritis requires certain criteria to have been present for at least six weeks. For most people, symptoms of rheumatoid arthritis begin gradually over a period of weeks or months. As such was not the case here, so it was unlikely that his rheumatoid arthritis had its onset during his active service or shortly after his discharge. See October 2008 VA Examination. The Board is mindful that the absence of evidence cannot be taken as substantive negative evidence without a proper foundation to demonstrate that such silence has a tendency to prove or disprove a relevant fact. Horn v. Shinseki, 25 Vet. App. 231, 239 (2012). In this case, however, the examiner has established a proper foundation to rely upon the absence of evidence: the American Rheumatological Association's diagnostic criteria could not have been met during the Veteran's period of service, because there was not a showing of certain symptoms for at least six weeks. Therefore, the Board affords much probative value to the independent medical opinion based on its very thorough discussion of the different types of arthritis, how they manifest, and application of those factors in the Veteran's case. The Veteran has submitted numerous letters written by his private treating physician, Dr. M.W., in support of his claim. In January 2005, Dr. M.W. wrote that the Veteran had ongoing rheumatoid arthritis. She indicated that the Veteran was diagnosed with rheumatoid arthritis in March 1999, but he had reported pain prior to that and dating back to his active service. In April 2005, Dr. M.W. again indicated that the Veteran had rheumatoid arthritis, and she requested reimbursement for any assistive devices he required. In October 2005, Dr. M.W. wrote that the Veteran had reported to her that he had symptoms of rheumatoid arthritis since 1968. "It is certainly possible," she wrote, "that his rheumatoid arthritis symptoms began at this time and have subsequently progressed." In March 2008, Dr. M.W. reiterated the Veteran's statements that he had experienced pain since service, and she observed that he had not undergone formal rheumatology evaluations at that time. Nonetheless, she wrote that it was "entirely possible" that the Veteran's rheumatoid arthritis had begun during service. In September 2015, Dr. M.W. wrote that she had treated the Veteran for both rheumatoid arthritis and osteoarthritis. In January 2018, Dr. M.W. wrote that due to his rheumatoid arthritis and osteoarthritis, the Veteran needed medications and exercise. In November 2019, Dr. M.W. wrote that the Veteran had been symptomatic for rheumatoid arthritis prior to his diagnosis in March 1999, though she did not assert a specific onset date for the condition. She cited to a scientific study published in Environmental Health Perspectives in 2009 that there was evidence of a linkage between exposure to trichloroethylene (TCE) and autoimmune diseases, such as rheumatoid arthritis. She further pointed to a case-control study (Lundberg study) of male workers who had been exposed to solvents with TCE and who demonstrated a 2-fold increased risk of rheumatoid arthritis compared to non-exposed men. See November 2019 Medical Treatment Record Non-Government Facility. The Board is mindful that Dr. M.W.'s opinions regarding the Veteran's onset of rheumatoid arthritis each used language suggesting a possibility of a linkage, but without stating how strong such possibilities actually were. As stated above, Dr. M.W. wrote that it was "entirely possible" or "certainly possible" that the Veteran's condition had long predated her diagnosis of the condition. However, such opinions are speculative, due to the use of "possible"; therefore, they hold reduced probative weight. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (stating that a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship).; see also Possible, Merriam-Webster; https://www.merriam-webster.com/dictionary/possible (defining, among other entries, "possible" as "being something that may or may not be true or actual"). Dr. M.W.'s opinions have not used language which denotes a causal relationship, to the level of equipoise, between the Veteran's condition and his military service, and therefore they do not, by themselves, establish a nexus as required by the third Shedden prong. In February 2020, VA obtained another medical opinion on the Veteran's rheumatoid arthritis based upon a review of his records. The examiner indicated review of the complete claim file, and the examiner additionally listed each of the academic journal and other studies submitted by the Veteran as part of that review, as well as the letters provided by the Veteran's private physician. The examiner wrote an opinion that the Veteran's rheumatoid arthritis condition was less likely than not (less than 50 percent probability) incurred in or caused by exposure to contaminated water at Camp Lejeune. The Veteran had increased risk for rheumatoid arthritis based upon his factors of age, weight, and his history of smoking, but he had a decreased risk based upon factors of family history, gender, and ethnicity. The opinion focused on the Veteran's exposure to contaminated water over a 38-day period at Camp Lejeune from July to August 1968. The examiner noted that the Agency for Toxic Substances and Disease Registry (ATSDR) study cited by the Veteran's private physician did not find an increased risk for rheumatoid arthritis due to exposure to Camp Lejeune drinking water. The Lundberg study did find increased risk for rheumatoid arthritis for workers who had reported heavy, "statistically significant" use of organic solvents. However, the Veteran's exposure to toxic chemicals was far lower than those workers' exposures, as he did not directly work with solvents and he was only assigned at Camp Lejeune for 38 days. In contrast, the workers in the Lundberg study had worked directly with toxic solvents for "ten times longer on average than the Veteran." The examiner additionally discussed the article cited by the Veteran's doctor which had found accelerated autoimmune response in mice after exposure to TCE in drinking water for 4 weeks, generally concluding that this study was not persuasive. The examiner observed that the Veteran's private doctor's letters had never addressed his high risk for rheumatoid arthritis due to his age group, weight, and his history of smoking. The examiner concluded that when the Veteran's risk factors were considered together, they outweighed the risks of developing an autoimmune response from drinking contaminated water years ago during service. See February 2020 Compensation and Pension (C&P) Examination. The Board affords high probative value to this opinion based upon the examiner's very thorough review of relevant evidence, awareness of relevant facts, such as the Veteran's medical history and risk factors, and discussion of the Veteran's medical records and relevant scientific studies of rheumatoid arthritis and chemical exposure. The Veteran has repeatedly stated that he believes his rheumatoid arthritis is due to service, whether it was from injury, exposure to Agent Orange, or exposure to toxic chemicals in Camp Lejeune drinking water. The Veteran is competent to report the occurrence of lay-observable events such as symptoms, to include pain, or certain readily-observable disabilities. 38 U.S.C. § 1154(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the Veteran is not competent to diagnose his own medical condition. Thus, the Board finds the Veteran's recounting of the facts of his injuries, and the Veteran's recounting of his experiences of pain and limitations with his hands, to be competent and probative. However, the Board cannot rely upon the Veteran's lay opinions that such pain and limitations were due to rheumatoid arthritis as the Veteran is not competent to provide an etiological opinion on a disease process, such as rheumatoid arthritis. As such, his statement in this regard lack weight. Also, due to lack of competency, the Board finds the Veteran's assertion that his rheumatoid arthritis began during military service lacks weight. The Veteran has also provided lay statements from several of his family members, which generally assert that he has suffered greatly as a result of his bilateral hand condition. The Board has no reason to doubt the credibility of any of those statements, and accepts them as competent and credible. However, none of those statements seek to link the Veteran's condition to his military service, nor does the record show that the Veteran's family members would be qualified to render such medical opinions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the Board finds they lack probative value and weight regarding the etiology of his currently diagnosed bilateral hand rheumatoid arthritis. In sum, the weight of the probative evidence does not support a finding that the Veteran's rheumatoid arthritis of the hands resulted from a disease or injury incurred in service, including exposure to herbicide agents including Agent Orange, or toxic chemicals in the drinking water at Camp Lejeune. The criteria for presumptive service condition have not been met for either Agent Orange exposure or for Camp Lejeune drinking water exposure. Rheumatoid arthritis is not a disease of the central nervous system, and therefore service connection may not be granted based on continuity of symptomatology. Turning to direct service connection, the competent and probative evidence does not tend to show that the Veteran's rheumatoid arthritis is related to his presumed Agent Orange exposure. Similarly, the competent and probative evidence does not tend to show the Veteran's rheumatoid arthritis is due to an injury/event in service. This stands to reason, since rheumatoid arthritis is an autoimmune condition, as stated by competent evidence of record, to include VA examiners and the Veteran's private physician. The evidence weighs against a finding that rheumatoid arthritis onset during service. To this point, the Board is persuaded by the October 2008 independent medical opinion, which noted that rheumatoid arthritis onsets slowly and requires six continuous weeks of symptomatic criteria to be diagnosed, whereas the Veteran's service medical records showed only two isolated instances of hand pain and one of those involved an acute injury resulting in a finger laceration. The evidence weighs against a finding that rheumatoid arthritis directly (rather than presumptively) resulted from exposure to toxic chemicals in the drinking water at Camp Lejeune, as stated by the February 2020 VA examiner. The Board reiterates that although the Veteran's private doctor has suggested a possible linkage between rheumatoid arthritis and service, the record does not show that she has ever suggested such a connection is more than a mere possibility. The Board finds the VA examiners' opinions and independent medical opinion to be more probative, and they do not show any such link. As the preponderance of evidence weighs against the claim, the benefit of the doubt doctrine is not for application and the claim for service connection is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). REASONS FOR REMAND 1. Entitlement to service connection for rheumatoid arthritis of bilateral hands, including as due to exposure to contaminated water at Camp Lejeune and as due to exposure to herbicide agents including Agent Orange, is remanded. A preliminary review of the medical evidence of record shows that further medical opinion is necessary before the Board may reach a decision in this matter. Examination and opinion in March 2007 discussed whether the Veteran's osteoarthritis was related to his finger laceration in January 1968. However, the opinion did not address the Veteran's contentions that his July 1968 report of hand pain might have indicated onset of osteoarthritis. The Independent Medical Opinion offered in October 2008 discussed both the incidents in the Veteran's service medical records, but the examiner did not discuss the Veteran's lay contentions that he has experienced hand pain since that time, including during his in-service work as a key punch technician. See January 2008 and June 2005 VA Form 9. Since the most recent denial by the Board, the Veteran has repeatedly expressed that he experienced pain in his hands since service, and no medical opinion of record directly addresses such contention. Based on foregoing, the issue is remanded for further medical opinion. 2. Entitlement to service connection for neurobehavioral effects, including as due to exposure to contaminated water at Camp Lejeune and as due to exposure to herbicide agents including Agent Orange, is remanded. The Veteran seeks service connection for certain neurobehavioral effects which he believes may be the result of exposure to toxic chemicals in Camp Lejeune water, or to his exposure to Agent Orange. The record does not show a diagnosis of a "neurobehavioral effect" condition, and the precise meaning of this phrase is unclear. However, the Veteran's claim described that these "neurobehavioral effects" include impairment of his immune system, short term memory, visual perception, attention, and color vision. See June 2013 VA Form 21-4138 Statement in Support of Claim. A review of the record shows a diagnosis of Cognitive Disorder NOS in 2013 following formal testing of his memory, attention, language, and visuospatial skills. See May 2020 VA Medical Treatment Record, p. 127 (May 29, 2013 Neuropsychology Note). The record suggests that such impairments might be secondarily caused by the Veteran's service-connected Type II Diabetes Mellitus. The Veteran has not received a VA examination for Cognitive Disorder NOS, or for other described neurobehavioral effects. The Board concludes that an examination and opinion are necessary to gather additional medical evidence before it can adjudicate this issue. McLendon v. Nicholson, 20 Vet. App. 79, 81-85 (2006). These matters are REMANDED for the following actions: 1. Schedule the Veteran for an examination to determine the nature and etiology of his bilateral hand osteoarthritis. The examiner should indicate review of the record, and should discuss the Veteran's history of osteoarthritis as well as the Veteran's lay statements that he has experienced hand pain since 1968, and during his in-service work as a punch key technician, until present. The examiner is to offer an opinion on whether it is at least as likely as not (approximately 50 percent or greater probability) that the Veteran's osteoarthritis onset during service or is otherwise related to service. The examiner must provide a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Schedule the Veteran for an examination to determine the nature and etiology of Cognitive Disorder NOS. The examiner should indicate review of the Veteran's complete record, including diagnosis of Cognitive Disorder NOS in May 2013, as well as any other diagnoses identified that may include the Veteran's description of "neurobehavioral effects" which includes impairment of his immune system, short term memory, visual perception, attention, and color vision. See June 2013 VA Form 21-4138 Statement in Support of Claim. The examiner should additionally consider the Veteran's presumed exposures to contaminated drinking water at Camp Lejeune and to herbicide agents in Vietnam as possible in-service events which led to his condition. The examiner is to offer opinions as follows: (a.) Is it at least as likely as not (approximately 50 percent or greater probability) that the Veteran's Cognitive Disorder NOS is secondarily caused or aggravated by another service-connected disability (specifically Type II Diabetes Mellitus)? (b.) Is it at least as likely as not (approximately 50 percent or greater probability) that the Veteran's Cognitive Disorder NOS was incurred in, caused by, or otherwise related to military service? A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Hermsdorfer, 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.