Citation Nr: 21068175 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 15-22 994 DATE: November 9, 2021 ORDER Entitlement to service connection for a sleep disorder diagnosed as insomnia is granted. REMANDED Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for right knee disability is remanded. Entitlement to service connection for left knee disability is remanded. Entitlement to service connection for a bilateral foot disability is remanded. Entitlement to service connection for a bilateral eye disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for low back disability is remanded. Entitlement to service connection for an upper back disability is remanded. FINDING OF FACT Resolving reasonable double in the Veteran's favor his claimed sleep disorder diagnosed as insomnia is at least as likely as not caused by his service-connected migraine headaches. CONCLUSION OF LAW The criteria for service connection for a sleep disorder diagnosed as insomnia have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1973 to August 1975. In June 2018, the Veteran testified at a video conference hearing (hearing) before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The Board denied the claims in November 2018. The Veteran appealed the November 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). Pursuant to the September 2019 order granting a Joint Motion for Partial Remand (JMPR), the Court vacated the Board's decision and remanded the Veteran's service connection claims to the Board for action consistent with the terms of the JMPR. See September 2019 JMPR. The parties agreed in the JMPR that the Board did not satisfy its duty to assist when it relied on inadequate VA medical opinions from January 2013 in denying the claims. This matter was previously remanded by the Board of Veterans Appeals (BVA) in April 2020 and May 2021 for additional development. It now returns for further appellate review. 1. Entitlement to service connection for a sleep disorder diagnosed as insomnia The Veteran contends that his insomnia was caused by his service-connected migraine headaches. See October 2012 Notice of Disagreement (NOD). Legal Criteria Service connection may be granted for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Establishing secondary service connection requires: (1) competent evidence of a current disability; (2) a service-connected disability; and (3) competent evidence that the current disability was either (a) caused or (b) aggravated by the service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Relevant Facts and Analysis With respect to the first element, the Board finds that the record in this case contains competent evidence of a current disability. The Veteran's VA treatment records confirm insomnia was an active problem and the Veteran was prescribed Ambien for his insomnia. See September 2016 VA Primary Care Follow-Up in CAPRI received February 2017. Thus, the first element of secondary service connection has been met. With respect to the second element, the Veteran is service-connected for migraine headaches. See August 2021 Rating Decision Codesheet. As such, the second element of service connection has been met. The question for the Board is whether the Veteran's insomnia was caused or aggravated by his service-connected migraine headaches, i.e., whether there is a nexus between his service-connected migraine headaches and insomnia. On this issue, the Board notes that the January 2013 VA examiner provided a negative nexus opinion. However, this opinion was not supported by adequate rationale and is entitled to no probative weight. See September 2019 JMPR. Similarly, the August 2020 VA medical opinion is not adequate for adjudication purposes because the examiner did not address whether the Veteran's insomnia was caused by his service-connected migraine headaches. See May 2021 Board Remand. As such, the Board will not address the August 2020 medial opinion. Pursuant to the May 2021 examination, the VA obtained another medical opinion in June 2021 for the Veteran's insomnia claim. See June 2021 Medical Opinion Disability Benefits Questionnaire (DBQ). The examiner opined that the Veteran's insomnia is at least as likely as not proximately due to or the result of the Veteran's migraine headaches. Id. In her rationale, the examiner quoted a medical journal which stated "'[r]esearch findings support an association between [tension-type headaches], migraine, and sleep disturbances. This association is bidirectional; headache can promote sleep disturbances, but sleep problems can also trigger headache." She also quoted another medical journal which stated "[m]igraines can be associated with primary sleep disorders, in particular, insomnia." Id. The Board assigns significant probative value to the June 2021 medical opinion. The VA examiner considered the Veteran's contention and supported her conclusion with medical journal articles that the Veteran's insomnia was caused by and related to his service-connected migraine headaches. In short, the June 2021 medical opinion substantiates the Veteran's claim. Therefore, resolving doubt in favor of the Veteran, the Board finds the evidence is at least in relative equipoise as to whether his insomnia was caused by his service-connected migraine headaches. Therefore, a grant of secondary service connection for insomnia is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Neck Disability and Upper Back Disability Regrettably, the Board finds another remand is necessary for the Veteran's claimed cervical spine and upper back disabilities in order to ensure compliance with the May 2021 Board remand and to obtain an adequate medical opinion, which complies with the September 2019 JMPR. The Board remanded the claim in May 2021 to obtain an addendum medical opinion as to the Veteran's neck and upper back disability, to address the Veteran's lay statements. See May 2021 Board Remand. Consequently, the June 2021 VA examiner found that the Veteran did not have a current diagnosed cervical spine or upper back disability. See June 2021 VA Neck (Cervical Spine) Conditions Disability Benefits Questionnaire (DBQ). The examiner provided the following remarks: Unable to access neck because veteran was belligerent and argumentative and refused to have neck assessed stating that "he has neuropathy and doesn't want to do all that standing and bending and stuff and fall and bust up his shoulder. And I don't know why they have to do that stuff anyways. That doesn't make sense." Also veteran was very insulting and disrespectful to provider including demeaning the provider's education. Also when asked about his occupational history to assess for any other possible causes for the veteran's claimed condition, veteran was very vague, not forthcoming and very uncooperative in providing occupational history during the 46 year period ETSing out of the Navy until present 2021. See June 2021 VA Neck (Cervical Spine) Conditions DBQ. In a separate medical opinion, the June 2021 VA examiner provided a negative nexus opinion and noted that he was "unable to assess neck, knees, shoulders, feet, and back because the Veteran was belligerent and argumentative and refused to have neck, knees, shoulders, feet, and back assessed...." See June 2021 VA Medical Opinion DBQ. He further stated that "[b]y refusing assessment it is impossible to ascertain if veteran had an actual current condition or if he was malingering." Id. Accordingly, the examiner opined his claimed conditions were less likely than not related to his active service. Id. Upon review, the Board finds that a new addendum medical opinion for the Veteran's cervical spine and upper back disability is necessary as the June 2021 medical opinion does not comply with the May 2021 Board remand because the examiner was unable to provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998)( A remand by the Board confers on the claimant, as a matter of law, a right to compliance with the remand orders.) Notably, the June 2021 VA medical opinion is inadequate for adjudication purposes because the examiner found that the Veteran did not have a diagnosed neck or upper back disability based on the Veteran's lack of cooperation. However, the claims file confirms the Veteran was diagnosed with cervical spine degenerative disc disease (DDD). See January 2013 Neck (Cervical Spine) DBQ. See also November 2011 VA X-ray Report (confirming mild DDD of the thoracic spine). As such, the June 2021 VA examiner's conclusion that the Veteran does not have a diagnosed neck or upper back disability is inaccurate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (A medical opinion based on an inaccurate factual premise has no probative value.) Thus, the Board finds a remand is warranted to obtain an addendum medical opinion for the Veteran's claimed neck and upper back disabilities that addresses the Veteran's lay statements and is supported by adequate rationale. However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. 2. Bilateral Knee Disability The Board also finds that the Veteran's left and right (bilateral) knee claims must be remanded for the same reasons as stated above. Notably, the June 2021 VA examiner found that the Veteran did not have a diagnosed bilateral knee disability due to the Veteran's lack of cooperation. See June 2021 VA Knee and Lower Leg Conditions DBQ. However, the claims file indicates that the Veteran has right knee osteoarthritis (see February 2016 VA Primary Care Follow Up, in CAPRI received November 2017) and the September 2020 VA medical opinion confirms the Veteran was diagnosed with left knee strain (see September 2020 VA Medical Opinion DBQ.) As such, the June 2021 VA examiner's conclusion that the Veteran does not have a diagnosed bilateral knee disability is inaccurate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (A medical opinion based on an inaccurate factual premise has no probative value.) Additionally, the June 2021 VA examiner provided a negative nexus opinion and noted that he was "unable to assess neck, knees, shoulders, feet, and back because the Veteran was belligerent and argumentative and refused to have neck, knees, shoulders, feet, and back assessed...." See June 2021 VA Medical Opinion DBQ. He further stated that "[b]y refusing assessment it is impossible to ascertain if veteran had an actual current condition or if he was malingering." Id. Accordingly, the examiner opined his claimed conditions were less likely than not related to his active service. Id. As the examiner provided a negative nexus opinion for the Veteran's bilateral knee disabilities based on lack of cooperation, the Board finds the opinion is not supported by adequate rationale. As such, a remand is necessary for an addendum medical opinion which addresses the Veteran's lay statements and is supported by adequate rationale. The Board also finds that the June 2021 VA medical opinion does not comply with the May 2021 Board remand because the examiner did not provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. 3. Bilateral Foot Disability The Board also finds that the Veteran's left and right (bilateral) knee claims must be remanded for the same reasons as stated above. Notably, the June 2021 VA examiner found that the Veteran did not have a diagnosed bilateral foot disability due to the Veteran's lack of cooperation. See June 2021 VA Foot Conditions DBQ. However, the September 2020 VA examination indicated the Veteran has bilateral foot degenerative arthritis. See September 2020 VA Foot Conditions DBQ. As such, the opinion is inadequate in light of Reonal v. Brown, 5 Vet. App. 458, 461. Similarly, the June 2021 VA examiner provided a negative nexus opinion for the Veteran's bilateral foot disabilities based on the Veteran's lack of cooperation. See June 2021 VA Medical Opinion DBQ. As the examiner provided a negative nexus opinion for the Veteran's bilateral foot disabilities based on lack of cooperation, the Board finds the opinion is not supported by adequate rationale. As such, a remand is necessary for an addendum medical opinion which addresses the Veteran's lay statements and is supported by adequate rationale. The Board also finds that the June 2021 VA medical opinion does not comply with the May 2021 Board remand because the examiner did not provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. 4. Bilateral Shoulder Disability The Board also finds that the Veteran's left and right (bilateral) shoulder claims must be remanded for the same reasons as stated above. Particularly, the June 2021 VA examiner found that the Veteran did not have a diagnosed bilateral shoulder disability due to the Veteran's lack of cooperation. See June 2021 VA Shoulder Conditions DBQ. However, the September 2020 VA examination confirmed that the Veteran has right shoulder acromioclavicular joint osteoarthritis and a left shoulder strain. See September 2020 VA Shoulder Conditions DBQ. As such, the opinion is inadequate in light of Reonal v. Brown, 5 Vet. App. 458, 461. Similarly, the June 2021 VA examiner provided a negative nexus opinion for the Veteran's bilateral shoulder disabilities based on the Veteran's lack of cooperation. See June 2021 VA Medical Opinion DBQ. As the examiner provided a negative nexus opinion for the Veteran's bilateral shoulder disabilities based on lack of cooperation, the Board finds the opinion is not supported by adequate rationale. As such, a remand is necessary for an addendum medical opinion which addresses the Veteran's lay statements and is supported by adequate rationale. The Board also finds that the June 2021 VA medical opinion does not comply with the May 2021 Board remand because the examiner did not provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. 5. Low Back Disability The Board also finds that the Veteran's low back disability claim must be remanded for the same reasons as stated above. Specifically, the June 2021 VA examiner found that the Veteran did not have a diagnosed low back disability due to the Veteran's lack of cooperation. See June 2021 VA Back (Thoracolumbar Spine) Conditions DBQ. However, the September 2020 VA examination confirmed that the Veteran has lumbar spine degenerative arthritis. See September 2020 VA Back Conditions DBQ. As such, the opinion is inadequate in light of Reonal v. Brown, 5 Vet. App. 458, 461. Similarly, the June 2021 VA examiner provided a negative nexus opinion for the Veteran's low back disability based on the Veteran's lack of cooperation. See June 2021 VA Medical Opinion DBQ. As the examiner provided a negative nexus opinion for the Veteran's low back disability based on lack of cooperation, the Board finds the opinion is not supported by adequate rationale. As such, a remand is necessary for an addendum medical opinion which addresses the Veteran's lay statements and is supported by adequate rationale. The Board also finds that the June 2021 VA medical opinion does not comply with the May 2021 Board remand because the examiner did not provide the requested medical opinions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). However, the Board notes that the record indicates that the Veteran was uncooperative during the June 2021 VA examinations. VA's duty to assist is a two-way street, and the Veteran cannot wait passively in those situations where his assistance to VA is necessary. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, upon remand the Veteran is reminded to fully cooperate with his VA examiner in order to assist in the development of his claim. 6. Bilateral Eye Disability Upon review of the June 2021 VA medical opinion for the Veteran's claimed eye disabilities, the Board finds a remand is warranted. Specifically, the examiner's medical was incomplete as discussed further below. The June 2021 VA examiner confirmed the Veteran's bilateral eye disabilities included bilateral nuclear sclerotic cataracts, bilateral dry eye, and bullous retinoschisis left eye. See June 2021 VA Eye Conditions DBQ. The examiner opined that the Veteran's bilateral eye disabilities were less likely than related to service because, these conditions were not diagnosed in service and were likely age related. See June 2021 VA Medical Opinion DBQ. Regarding, the Veterans right eye Myokymia, the examiner opined that it was less likely than not caused by the Veteran's service-connected disabilities because he had nonpathological Myokymia and that it "is not associated with any service-connected disease." Id. However, the examiner did not address whether the Veteran's right eye Myokymia was aggravated (any incremental increase) by his service-connected disabilities. See El Amin v. Shinseki, 26 Vet. App. 140 (2013)( A medical opinion regarding secondary service connection must address both causation and aggravation.) Notably, the May 2021 Board remand instructed the examiner to address to address whether there was a causal relationship between his eye disability and his service-connected migraine headaches because fatigue was a listed factor for Myokymia. In this regard, the June 2021 VA examiner stated that Myokymia was caused by caffeine, or not getting enough sleep but did not address whether the Veteran's migraine headaches caused fatigue or sleep disturbance which led to Myokymia. The Board also notes that the Veteran's is now service connected for insomnia. As such, on remand the VA examiner should address whether the Veteran's right eye Myokymia was caused or aggravated by any of his service-connected disabilities including migraine headaches and/or insomnia. Thus, for the reasons discussed above, the Board remands the Veteran's bilateral eye disability claims for an addendum medical opinion which addresses aggravation and causation. VA Treatment Records The Board notes the claims file reflects that the Veteran has been receiving treatment from the Houston VA Medical Center (VAMC), and that records dated through July 2021 are associated with the file; however, more recent records may exist. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016). The matters are REMANDED for the following action: 1. Obtain the Veteran's comprehensive VA treatment records for the period from July 2021to the present, to include from VA medical centers, clinics, counseling centers, hospitals, and outpatient treatment centers. See 38 C.F.R. § 3.159(c)(3) (2020). The Board observes that the Veteran has been treated at Houston VAMC. Neck, Upper Back, Bilateral Knees, Bilateral Shoulders, Bilateral Feet, and Low Back Disabilities 2. Obtain an addendum opinion from an examiner OTHER THAN THE JUNE 2021 VA examiner with appropriate experience to render an etiology opinion for the Veteran's neck, upper back, bilateral knees, bilateral shoulders, bilateral feet, and low back disabilities. A VA examination is not required. However, if the examiner determines that an opinion may not be offered without first examining the Veteran, then schedule the Veteran for an appropriate examination(s). Any clinically indicated testing and/or consultations should be performed. If an in-person examination is required, the Veteran must be provided written notice of the time and place of the examination. A copy of the notice letter sent to the Veteran informing him of the time, place, and location of the examination must be associated with the Veteran's electronic claims file. The letter should also inform the Veteran of the consequence of any failure to report for the examination without good cause. See 38 C.F.R. § 3.655. Neck, Upper Back, and Low Back Disabilities 3. The examiner must review the claims folder including this remand and acknowledge such review in the report. Based on review of the January 2013 and September 2020 VA examination reports and medical opinions, the examiner is requested to address the following. 4. Identify the Veteran's current neck, upper back, and lower back disabilities. 5. If arthritis is found, the examiner should opine whether it at least as likely as not any arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 6. Assuming that the standard is at least as likely as not, is it possible that the Veteran's current neck, upper back, and lower back disabilities could be related to or caused by the in-service injury from active service as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim)? 7. Are the Veteran's assertions that his current neck, upper back, and lower back disabilities was incurred as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim), consistent with medical knowledge or implausible? 8. Do the Veteran's reports about his symptoms or his in-service injury from as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim), align with how the Veteran's current neck, upper back, and lower back disabilities are known to develop? 9. Whether it is medically feasible that his current neck, upper back, and lower back disabilities was caused by his in-service injury as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim)? (a.) If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. (b.) If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. THE EXAMINER MUST DISCUSS THE VETERAN'S LAY STATEMENTS REGARDING THE HISTORY, CHRONICITY, AND CONTINUITY OF SYMPTOMATOLOGY, TO INCLUDE THE VETERAN'S REPORT OF HIS IN-SERVICE INJURY. S/HE SHOULD OUTLINE THAT HISTORY IN THE REPORT. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. Bilateral Shoulder Disabilities 10. Request an addendum opinion from a qualified medical professional, OTHER THAN THE JUNE 2021 VA EXAMIENR, to ascertain the nature and etiology of the Veteran's bilateral shoulder conditions(s). Upon review of the evidence, the VA examiner is asked to address the following: 11. Identify the Veteran's current bilateral shoulder disabilities. 12. Opine whether the Veteran's currently diagnosed bilateral shoulder disabilities, are at least as likely as not (probability of 50 percent or greater) the result of a disease or injury incurred in or aggravated by service. 13. If arthritis is found, the examiner should opine whether it at least as likely as not any arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 14. Assuming that the standard is at least as likely as not, is it possible that the Veteran's bilateral shoulder disabilities could be related to or caused by the in-service injury from active service as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim)? 15. Are the Veteran's assertions that his bilateral shoulder disabilities was incurred as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim), consistent with medical knowledge or implausible? 16. Do the Veteran's reports about his symptoms or his in-service injury from as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim), align with how the Veteran's current bilateral shoulder disabilities are known to develop? 17. Whether it is medically feasible that his bilateral shoulder disabilities was caused by his in-service injury as a result of working as a mechanic and lifting heavy engine parts in awkward positions (see June 2012, VA Form 21-4138, Statement in Support of Claim)? (a.) If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. (b.) If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. THE EXAMINER MUST DISCUSS THE VETERAN'S LAY STATEMENTS REGARDING THE HISTORY, CHRONICITY, AND CONTINUITY OF SYMPTOMATOLOGY, TO INCLUDE THE VETERAN'S REPORT OF HIS IN-SERVICE INJURY. S/HE SHOULD OUTLINE THAT HISTORY IN THE REPORT. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. Bilateral foot disabilities 18. Request an addendum opinion from a qualified medical professional, OTHER THAN THE JUNE 2021 VA EXAMIENR, to ascertain the nature and etiology of the Veteran's bilateral foot disabilities. Upon review of the evidence, the VA examiner is asked to address the following: 19. Identify the Veteran's currently diagnosed bilateral foot disabilities. 20. Opine whether the Veteran's currently diagnosed bilateral foot disabilities, are at least as likely as not (probability of 50 percent or greater) the result of a disease or injury incurred in or aggravated by service. 21. If arthritis is found, the examiner should opine whether it at least as likely as not any arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 22. Assuming that the standard is at least as likely as not, is it possible that the Veteran's bilateral foot disabilities could be related to or caused by the in-service injury from active service as a result of working as a mechanic while standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript)? 23. Are the Veteran's assertions that his bilateral foot disabilities were incurred as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript), consistent with medical knowledge or implausible? 24. Do the Veteran's reports about his symptoms or his in-service injury from as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript), align with how the Veteran's current bilateral foot disabilities are known to develop? 25. Whether it is medically feasible that his bilateral foot disabilities were caused by his in-service injury as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript)? (a.) If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. (b.) If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. THE EXAMINER MUST DISCUSS THE VETERAN'S LAY STATEMENTS REGARDING THE HISTORY, CHRONICITY, AND CONTINUITY OF SYMPTOMATOLOGY, TO INCLUDE THE VETERAN'S REPORT OF HIS IN-SERVICE INJURY. S/HE SHOULD OUTLINE THAT HISTORY IN THE REPORT. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. Bilateral knee disabilities 26. Request an addendum opinion from a qualified medical professional, OTHER THAN THE JUNE 2021 VA EXAMIENR, to ascertain the nature and etiology of the Veteran's bilateral knee disabilities. Upon review of the evidence, the VA examiner is asked to address the following: 27. Identify the Veteran's currently diagnosed bilateral knee disabilities. 28. Opine whether the Veteran's currently diagnosed bilateral knee disabilities, are at least as likely as not (probability of 50 percent or greater) the result of a disease or injury incurred in or aggravated by service. 29. If arthritis is found, the examiner should opine whether it at least as likely as not any arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 30. Assuming that the standard is at least as likely as not, is it possible that the Veteran's bilateral knee disabilities could be related to or caused by the in-service injury from active service as a result of working as a mechanic while standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript)? 31. Are the Veteran's assertions that his bilateral knee disabilities were incurred as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript), consistent with medical knowledge or implausible? 32. Do the Veteran's reports about his symptoms or his in-service injury from as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript), align with how the Veteran's current bilateral knee disabilities are known to develop? 33. Whether it is medically feasible that his bilateral knee disabilities were caused by his in-service injury as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript)? (a.) If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. (b.) If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. THE EXAMINER MUST DISCUSS THE VETERAN'S LAY STATEMENTS REGARDING THE HISTORY, CHRONICITY, AND CONTINUITY OF SYMPTOMATOLOGY, TO INCLUDE THE VETERAN'S REPORT OF HIS IN-SERVICE INJURY. S/HE SHOULD OUTLINE THAT HISTORY IN THE REPORT. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. Bilateral Eye Disabilities 34. Forward the claims file, to the June 2021 VA examiner for an addendum medical opinion for the Veteran's bilateral eye disabilities. Upon review of the evidence, the VA examiner is asked to address the following: 35. Identify the Veteran's currently diagnosed eye disabilities. 36. Opine whether it is at least as likely as not that the Veteran's bilateral eye disabilities are related to an in-service, to include his contention that particulates got in eyes during service while working as a mechanic (see June 2018 Hearing Transcript)? 37. Assuming that the standard is at least as likely as not, is it possible that the Veteran's bilateral eye disabilities could be related to or caused by the in-service injury from active service as a result of particulates got in eyes during service while working as a mechanic (see June 2018 Hearing Transcript)? 38. Are the Veteran's assertions that his bilateral eye disabilities were incurred as a result of particulates got in eyes during service while working as a mechanic (see June 2018 Hearing Transcript), consistent with medical knowledge or implausible? 39. Do the Veteran's reports about his symptoms or his in-service injury from as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript), align with how the Veteran's current bilateral eye disabilities are known to develop? 40. Whether it is medically feasible that his bilateral eye disabilities were caused by his in-service injury as a result of working as a mechanic and as a result of working standing on his feet on cement and wearing boots (see June 2018 Hearing Transcript)? (a.) If the answer to any of the above questions is negative, state why not and on what basis this conclusion was made. (b.) If any answer to any of the above questions is positive, state why and on what basis this conclusion was made. 41. Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's bilateral eye disabilities were caused or are due to any service-connected disabilities including insomnia and migraine headaches. (a.) The examiner is asked to address whether fatigue caused by insomnia and migraine headaches is related to the Veteran's right eye Myokymia. 42. Whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's bilateral eye disabilities underwent an incremental increase (aggravated), regardless of permanence, by any of his service-connected disabilities including insomnia and migraine headaches. The term incremental increase in disability means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any incremental increase in disability need not be permanent. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. 43. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Lilly, 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.