Citation Nr: 21069178 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 20-08 234 DATE: November 17, 2021 ORDER Entitlement to service connection for hypertension as due to service-connected posttraumatic stress disorder (PTSD) is granted. Entitlement to service connection for bilateral carpal tunnel syndrome is denied. Entitlement to service connection for a bilateral knee disability is denied. Entitlement to service connection for bilateral pes planus is denied. Entitlement to service connection for a cardiac disability, including as due to service-connected PTSD, is denied. Entitlement to service connection for a pulmonary disability, to include chronic pulmonary thromboembolism, is denied. REMANDED Entitlement to service connection for a lumbosacral spine disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. FINDINGS OF FACT 1. The record evidence reasonably supports finding that the Veteran's service-connected PTSD caused or contributed to her current hypertension. 2. The record evidence shows that the Veteran does not experience any current disability due to her claimed bilateral carpal tunnel syndrome, bilateral knee disability, bilateral pes planus, or cardiac disability which could be attributed to active service. 3. The record evidence shows that the Veteran's pulmonary disability, to include chronic pulmonary thromboembolism, is not related to active service. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension as due to service-connected PTSD have been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2020). 2. The criteria for service connection for bilateral carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2020). 3. The criteria for service connection for a bilateral knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2020). 4. The criteria for service connection for bilateral pes planus have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2020) 5. The criteria for service connection for a cardiac disability, including as due to service-connected PTSD, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2020). 6. The criteria for service connection for a pulmonary disability, to include chronic pulmonary thromboembolism, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.304 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from March 1988 to March 1998. In October 2020, the Board remanded, in pertinent part, all of the Veteran's currently appealed claims to the Agency of Original Jurisdiction (AOJ) for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives to the extent possible. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Having reviewed the record evidence, the Board finds that the issues on appeal should be characterized as stated above. The Board notes that, among the remand directives contained in the October 2020 remand, it directed that the AOJ attempt to obtain certain of the Veteran's service treatment records dated in 1997 from Charleston Air Force Base Hospital when she allegedly was involved in a motor vehicle accident. The record evidence shows that, following the Board's remand, the AOJ requested these records on multiple occasions from the National Personnel Records Center in St. Louis, Missouri ("NPRC"), but did not receive a response (positive or negative) or any records from this facility. It is not clear to the Board why these records were not provided after being requested although there are scattered references in the record that these requests may have delayed by facility closures due to COVID-19. The AOJ also requested that the Veteran provide any relevant records in her possession and she responded that she had no records. She waived AOJ jurisdiction over any records which could be obtained in response to VA's requests for them in May 2021 correspondence. In August 2021, she requested that VA stop attempting to obtain these records given the unusual delays encountered in attempting to locate them and informed VA that she had no more evidence to submit in support of her appeal. She reiterated that she had no more evidence to submit in support of her appeal in October 2021 correspondence. Given the Veteran's request to stop attempting to locate these records, the Board finds that the AOJ's apparent inability to obtain certain of her service treatment records dated in 1997 from Charleston Air Force Base Hospital when she allegedly was involved in a motor vehicle accident constitutes harmless error. See also Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), rev'd sub nom., Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing harmless error). The Board also finds that it may adjudicate this appeal without prejudice to the Veteran in not obtaining these records. The Veteran appointed her attorney to represent her before VA by filing a completed VA Form 21-22a at the AOJ in September 2021. The Board notes that the Veteran disputed the results of pulmonary function testing obtained in September 2021 in correspondence submitted to VA later that same month. In advancing an argument concerning the adequacy of this medical evidence, the Veteran appears to be raising a general challenge to the professional competence of the VA examiner who provided the September 2021 medical nexus opinion and conducted the September 2021 VA respiratory conditions Disability Benefits Questionnaire (DBQ). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that a Veteran is required to raise a specific challenge to the competency of a VA examiner before VA is required to respond with information about the qualifications of the examiner. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011), and Francway v. Wilkie, No. 2018-2136 (Fed. Cir. Oct. 15, 2019) (finding that a Veteran is required to challenge a VA examiner's competence in the first instance). Neither the Veteran nor her attorney has raised a specific challenge to the professional medical competence or qualifications of the September 2021 VA examiner. In other words, the appellant has not satisfied the requirement of raising a specific challenge to the September 2021 VA examiner's competence in the first instance. As a result, VA is not required to support its decision in this appeal by presenting information about this examiner's qualifications. Id. Other Federal Circuit precedent also suggests that VA may rely upon the September 2021 medical nexus opinion and the September 2021 VA respiratory conditions DBQ in adjudicating the claim of service connection for a pulmonary disability. In Bastien, an appellant challenged the qualifications of a VA physician to provide a medical expert opinion on the grounds that this physician lacked objectivity and/or independence because he was a VA employee. See Bastien, 599 F.3d at 1306-7. Citing Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009), the Federal Circuit in Bastien rejected the appellant's challenge to the qualifications of a VA physician and held instead that the law and regulations provide that VA "is explicitly and implicitly authorized to use its own employees as experts." See Bastien, 599 F.3d at 1307 (citing 38 U.S.C. §§ 5103A(d), 7109(a); 38 C.F.R. § 20.901). The Federal Circuit also held in Bastien that an appellant challenging the expertise of a VA physician must "set forth the specific reasons...that the expert is not qualified to give an opinion." Id. That has not happened in this case. Neither the Veteran nor her attorney has identified or submitted any evidence or argument that the September 2021 VA respiratory conditions DBQ examiner was not competent or lacked the professional medical training necessary to review the claims file, including the Veteran's service treatment records and post-service VA and private treatment records, and provide a competent opinion concerning the contended etiological relationship between her pulmonary disability and active service. The Federal Circuit noted in Rizzo that there was "no law or precedent suggesting that the Board must have first established [a VA examiner's] qualifications on the record before assigning his opinion probative value." See Rizzo, 580 F.3d at 1291 92. Instead, as the Federal Circuit held in Francway, although there is no longer a presumption of competence for VA examiners (as Rizzo previously was interpreted), a Veteran nevertheless is required to challenge a VA examiner's competence in the first instance before VA is required to present evidence of the examiner's professional qualifications in order to rebut this challenge. See Francway v. Wilkie, No. 2018-2136 (Fed. Cir. Oct. 15, 2019) (overruling, in relevant part, Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009), and Bastien v. Shinseki, 599 F.3d 1301 (Fed. Cir. 2010) to the extent that those cases established a presumption of competence for VA examiners). It is presumed that VA follows a regular process that ordinarily results in the selection of a competent medical professional. Parks v. Shinseki, 716 F.3d 581, 585 (Fed. Cir. 2013) (citing Sickels v. Shinseki, 643 F.3d 1362, 1366 (Fed. Cir. 2011)). Accordingly, and as the Federal Circuit explained in Francway, if the Veteran does not meet the requirement to challenge a VA examiner's competence in the first instance, then VA is not required to prove any examiner's competence before relying on medical evidence obtained from the examiner in adjudicating this appeal. See Francway v. Wilkie, No. 2018-2136 (Fed. Cir. Oct. 15, 2019). There has been no showing or even an allegation that the September 2021 VA examiner was not competent or did not report accurately what she found in her review of the claims file. The Veteran's September 2021 complaint regarding pulmonary function testing appears to be related to how the VA examiner conducted this testing. The Board also finds that the September 2021 medical opinion is adequate for evaluation purposes because it addressed fully all of the Veteran's contentions regarding her pulmonary disability. Service Connection 1. Entitlement to service connection for hypertension, including as due to service-connected PTSD The Board finds that the evidence reasonably supports granting the Veteran's claim of service connection for hypertension as due to service-connected PTSD. The Veteran essentially contends that she incurred hypertension during active service and experienced continuous post-service disability. She alternatively contends that her service-connected PTSD caused or contributed to her hypertension. The record evidence supports her assertions regarding the contended etiological relationship between hypertension and her service-connected PTSD. It is undisputed that the Veteran has been diagnosed as having and treated for hypertension since her service separation and service connection is in effect for PTSD. Her voluminous post-service VA outpatient treatment records document ongoing complaints of and treatment for hypertension. The Board notes here that, in directing the AOJ to obtain new medical nexus opinions on remand, it essentially found that medical nexus opinions from a VA clinician dated in May 2018 (including concerning the nature and etiology of the Veteran's hypertension) were inadequate for VA adjudication purposes in the October 2020 remand. Thus, these opinions were not reviewed or relied upon in adjudicating the service connection claim for hypertension. In an October 2021 opinion, a private physician opined that it was at least as likely as not that the Veteran's service-connected PTSD caused or contributed to her hypertension. The rationale for this opinion was based on a review of the medical evidence and relevant medical literature. The Veteran has asserted consistently that her service-connected PTSD caused or contributed to her hypertension. The record evidence (October 2021 private physician's opinion) supports these assertions by finding an etiological link between service-connected PTSD and hypertension. The October 2021 private physician's opinion concerning the contended etiological link between service-connected PTSD and hypertension was fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In summary, and after resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for hypertension as due to service-connected PTSD is warranted. 2. Entitlement to service connection for bilateral carpal tunnel syndrome, a bilateral knee disability, bilateral pes planus, and for a cardiac disability, including as due to service-connected PTSD The Board next finds that the preponderance of the evidence is against granting the Veteran's claims of service connection for bilateral carpal tunnel syndrome, a bilateral knee disability, bilateral pes planus, and for a cardiac disability, including as due to service-connected PTSD. The Veteran essentially contends that she incurred each of these claimed disabilities during active service. She alternatively contends that her service-connected PTSD caused or contributed to her claimed cardiac disability. The record evidence does not support her assertions regarding the existence of current disability which could be related to active service. It shows instead that she does not experience any current disability due to her claimed bilateral carpal tunnel syndrome, bilateral knee disability, bilateral pes planus, or cardiac disability which could be related to active service. The available service treatment records show that the Veteran complained of and sought treatment for chest pain on several occasions during active service. For example, she reported intermittent chest pain. A July 1994 exercise stress test was normal and she denied experiencing chest pain. In August 1994, she denied any medical history of heart disease. In October 1995, a history of atypical chest pain secondary to anxiety was noted. Her cardiac stress test and echocardiogram were normal. The Board notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). The post-service evidence also does not support granting service connection for bilateral carpal tunnel syndrome, a bilateral knee disability, bilateral pes planus, and for a cardiac disability, including as due to service-connected PTSD. Despite the Veteran's lay assertions to the contrary, it shows instead that she does not experience any current disability due to her claimed bilateral carpal tunnel syndrome, a bilateral knee disability, bilateral pes planus, or cardiac disability which is related to active service. Her voluminous post-service VA outpatient treatment records show no complaints of or treatment for any of these claimed disabilities. On VA heart conditions Disability Benefits Questionnaire (DBQ) in May 2018, the Veteran's complaints included chest pain and a rapid heart rate. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. This examiner stated that there was no evidence in the claims file "supporting a heart condition" although he noted that the Veteran's VA outpatient treatment "Problem List" in these records listed a history of tachycardia and atypical chest pain. None of the Veteran's claimed heart conditions qualified within the generally accepted medical definition of ischemic heart disease. The Veteran did not have myocardial infarction, congestive heart failure, cardiac arrhythmia, a heart valve condition, an infectious heart condition, or pericardial adhesions. Physical examination showed a regular heart rate and rhythm, normal heart sounds, no jugular venous distention, clear lungs, normal peripheral pulses, no peripheral edema, and blood pressure 124/75. There was no evidence of cardiac hypertrophy or cardiac dilatation. An echocardiogram showed left ventricular ejection fracture (LVEF) of 55-60 percent of predicted value, normal chest wall motion, and normal chest wall thickness. The VA examiner concluded that the Veteran did not have and had not been diagnosed as having a heart condition. As noted above, the Board essentially found that medical nexus opinions from a VA clinician dated in May 2018 (including concerning the nature and etiology of the Veteran's claimed cardiac disability) were inadequate for VA adjudication purposes in the October 2020 remand. Thus, these opinions were not reviewed or relied upon in adjudicating the service connection claim for a cardiac disability, including as due to service-connected PTSD. On VA heart conditions DBQ in September 2021, the Veteran's complaints included chest pain of unknown etiology. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. None of the Veteran's claimed heart conditions qualified within the generally accepted medical definition of ischemic heart disease. The Veteran did not have myocardial infarction, congestive heart failure, cardiac arrhythmia, a heart valve condition, an infectious heart condition, or pericardial adhesions. Physical examination showed a regular heart rate and rhythm, normal heart sounds, no jugular venous distention, clear lungs, normal peripheral pulses, no peripheral edema, and blood pressure 149/75. There was evidence of cardiac hypertrophy on echocardiogram. An EKG was normal and showed no cardiac hypertrophy. An echocardiogram showed left ventricular hypertrophy (LVH). A coronary artery angiogram was normal. An exercise stress test taken in October 2015 was negative for ischemia. Cardiac function was within normal limits. There was no ischemic heart diagnosis. There also was "no sign of cardiac issue as etiology of chest pain; LVH noted on last echo[cardiogram], not seen on prior" echocardiogram. The VA examiner stated that she was "unable to diagnose a heart disease at this point." This examiner concluded that the Veteran did not have and had not been diagnosed as having a heart condition. The Board acknowledges that, in October 2021, a private physician opined that it was at least as likely as not that the Veteran's cardiac disability is related to active service, including as due to her service-connected PTSD. This physician also opined that it was at least as likely as not that the Veteran's obesity caused or contributed to her bilateral knee disability which "has already been deemed secondary to her service connected PTSD." The rationale for these opinions was based on a review of the claims file and relevant medical literature. The Court has held that the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). A medical opinion based upon an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). A bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The Court also has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his [or her] opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Having reviewed the October 2021 private physician's opinion, the Board finds that it is not probative on the issues of whether the Veteran's claimed cardiac disability or bilateral knee disability is related to active service. With respect to the claimed cardiac disability, this opinion is based on the inaccurate factual premise that the Veteran currently experiences cardiac disability which is related to active service. VA examiners in May 2018 and October 2021 both found that the Veteran did not have and had not been diagnosed as having a heart condition. In contrast to the October 2021 private clinician's opinion, these VA clinician's opinions were fully supported. See Stefl, 21 Vet. App. at 124. With respect to the claimed bilateral knee disability, the October 2021 opinion incorrectly states that the Veteran's obesity is related to her service-connected PTSD when, in fact, service connection is not in effect for obesity. Thus, the October 2021 private physician's opinion is not probative on the issues of whether the claimed cardiac disability or the claimed bilateral knee disability is related to active service. A service connection claim must be accompanied by evidence which establishes that the claimant currently has a disability. Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection is not warranted in the absence of proof of current disability. The Board has considered whether the Veteran experienced bilateral carpal tunnel syndrome, a bilateral knee disability, bilateral pes planus, or a cardiac disability at any time during the pendency of this appeal. Service connection may be granted if there is a disability at some point during the claim even if it later resolves or becomes asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007). In this case, however, there is no evidence other than the Veteran's unsupported lay assertions that she experiences any current disability due to any of these claimed disabilities which could be attributed to active service. The Board already has found the October 2021 private physician's opinion to be not probative on the issues of whether the Veteran's service-connected PTSD caused or contributed to her claimed cardiac disability and whether the claimed bilateral knee disability is related to active service (as discussed above). She otherwise has not identified or submitted any evidence demonstrating her entitlement to service connection for bilateral carpal tunnel syndrome, a bilateral knee disability, bilateral pes planus, and for a cardiac disability, including as due to service-connected PTSD. In summary, the Board finds that service connection for bilateral carpal tunnel syndrome, a bilateral knee disability, bilateral pes planus, and for a cardiac disability, including as due to service-connected PTSD, is not warranted. 3. Entitlement to service connection for a pulmonary disability, to include chronic pulmonary thromboembolism The Board finally finds that the preponderance of the evidence is against granting the Veteran's claim of service connection for a pulmonary disability, to include chronic pulmonary thromboembolism. The Veteran essentially contends that she incurred a pulmonary disability, to include chronic pulmonary thromboembolism, during active service and experienced continuous post-service disability. The record evidence does not support her assertions regarding an etiological link between a pulmonary disability, to include chronic pulmonary thromboembolism, and active service. It shows instead that this disability is not related to active service. The available service treatment records show the Veteran complained of and sought treatment for a variety of pulmonary problems during active service. For example, she was diagnosed as having and treated for rule-out bronchitis, an upper respiratory infection, and viral syndrome in January 1991. Spirometry conducted in August 1992 showed moderate restrictive airways. She also complained of and was treated for an upper respiratory infection on several subsequent occasions during active service. The post-service evidence also does not support granting service connection for a pulmonary disability, to include chronic pulmonary thromboembolism. Contrary to the Veteran's lay assertions, it shows instead that, although she complained of and sought treatment for a variety of pulmonary problems since her service separation, her pulmonary disability, to include chronic pulmonary thromboembolism, is not related to active service. For example, on VA respiratory conditions DBQ in September 2018, the Veteran's complaints included shortness of breath and bilateral leg swelling as a result of chronic pulmonary thromboembolism. A history of hospitalization for this disability in 2007 and in 2015 was noted. Her respiratory condition did not require the use of oral or parenteral corticosteroids, inhaled medications, oral bronchodilators, or antibiotics. She experienced chronic pulmonary thromboembolism which required anticoagulant therapy. A recent scan had shown no changes to the Veteran's chronic pulmonary thromboembolism since a prior scan in April 2016. Pulmonary function testing showed an FVC of 82 percent of predicted value, an FEV-1 of 87 percent or predicted value, and an FEV-1/FVC of 105 percent of predicted value. Pre-bronchodilator results were normal. The VA examiner stated that the Veteran's pulmonary function testing was not valid for rating purposes due to her poor effort. The VA examiner opined that it was less likely than not that the Veteran's respiratory condition is related to active service. The rationale for this opinion was based on a review of the claims file which showed acute in-service treatment for bronchitis. The rationale also was that, although the Veteran's current respiratory problems were related to her chronic pulmonary thromboembolism, "there is no medical relationship between chronic pulmonary thromboembolism and acute bronchitis. These are two separate medical conditions entirely." The diagnosis was chronic pulmonary thromboembolism. On VA respiratory conditions DBQ in September 2021, the Veteran's complaints included chronic dyspnea on exertion. The VA examiner reviewed the Veteran's electronic claims file, including service treatment records and post-service VA treatment records. The Veteran's respiratory condition did not require the use of oral or parenteral corticosteroids, inhaled medications, oral bronchodilators, or antibiotics. She experienced chronic pulmonary thromboembolism which required anticoagulant therapy. A chest x-ray was negative. A computerized tomography (CT) scan of the Veteran's chest showed chest and mediastinal structures within normal limits except for acute pulmonary embolus in the right main pulmonary artery extending into the right lower lobe artery and left lower lobe proximal segmental arteries. The VA examiner stated that the Veteran had not been diagnosed as having asthma despite multiple pulmonary evaluations and despite prescriptions for an inhaler. This examiner also stated, "[T]he spirometry has been consistently without sign of obstruction." Pulmonary function testing showed FVC of 80 percent of predicted value, an FEV-1 of 86 percent of predicted value, and an FEV-1/FVC of 106 percent of predicted value (pre-bronchodilator). Post-bronchodilator, the Veteran's FVC was 81 percent of predicted value, FEV-1 was 89 percent of predicted value, and FEV-1/FVC was 108 percent of predicted value. The VA examiner opined that it was less likely than not that the Veteran's pulmonary disability is related to active service. The rationale for this opinion was based on a review of the claims file. The rationale also was that the Veteran's in-service complaints of non-cardiac chest pain were considered idiopathic and more recent incidences of non-cardiac chest pain were not related to anything which happened during service. The rationale further was that the Veteran's episodes of pulmonary embolism occurred prior to her being placed on permanent anticoagulant medication. The rationale finally was that the medical evidence suggested that the Veteran's deconditioning was a "major part of [the] etiology of [her] current subjective pulmonary complaint[s]." The diagnosis was pulmonary embolism. In an October 2021 opinion, a private physician opined that it was at least as likely as not that the Veteran's service-connected PTSD caused or contributed to her pulmonary disability, to include pulmonary embolism. The rationale for this opinion was that the Veteran's obesity caused or contributed to her service-connected PTSD which caused or contributed to her pulmonary disability. The Board finds that the October 2021 private physician's opinion is not probative on the issue of whether the Veteran's current pulmonary disability, to include chronic pulmonary thromboembolism, is related to active service. As noted elsewhere, this opinion incorrectly states that the Veteran's obesity is related to her service-connected PTSD when, in fact, service connection is not in effect for obesity. Thus, this opinion is based on an inaccurate factual premise and is entitled to no probative value on the issue of whether a pulmonary disability, to include chronic pulmonary thromboembolism, is related to active service. See, for example, Wilson, 2 Vet. App. at 614, and Reonal, 5 Vet. App. at 461. Contrary to the Veteran's lay assertions, the record evidence shows that her current pulmonary disability, to include chronic pulmonary thromboembolism, is not related to active service. Both VA examiners in September 2018 and in September 2021 opined that it was less likely than not that the Veteran's pulmonary disability, to include chronic pulmonary thromboembolism, is related to active service. These opinions were fully supported. See Stefl, 21 Vet. App. at 124. The Board already has found the October 2021 private physician's opinion not probative on the issue of whether the current pulmonary disability, to include chronic pulmonary thromboembolism, is related to active service (as discussed above). The Veteran otherwise has not identified or submitted any evidence demonstrating her entitlement to service connection for a pulmonary disability, to include chronic pulmonary thromboembolism. In summary, the Board finds that service connection for pulmonary disability, to include chronic pulmonary thromboembolism, is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a lumbosacral spine disability is remanded. The Veteran contends that she incurred a lumbosacral spine disability during active service and experienced continuous post-service disability. The Board acknowledges that this disability was examined for VA adjudication purposes in May 2018. Unfortunately, a review of the May 2018 VA medical nexus opinion shows that it is unlikely to survive judicial review. The May 2018 VA back (thoracolumbar spine) conditions DBQ examiner opined that it was less likely than not that the Veteran's current lumbosacral spine disability is related to active service. The rationale for this opinion was based on the lack of a diagnosis of a low back (or lumbosacral spine) disability in the available service treatment records. The addendum opinion obtained in September 2018 concerning the nature and etiology of the Veteran's lumbosacral spine disability also relied on the absence of records showing a diagnosis of a lumbosacral spine disability as support for the negative medical nexus opinion. It is well-settled that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. Thus, the Board finds that the May and September 2018 VA medical nexus opinions concerning the Veteran's lumbosacral spine disability are inadequate for VA adjudication purposes. The Board also acknowledges that a different VA clinician opined in September 2021 that it was less likely than not that the Veteran's current lumbosacral spine disability was aggravated by service. The September 2021 clinician was not asked to provide and did not provide an opinion concerning the contended etiological relationship between this disability and active service on a direct service connection basis. See 38 C.F.R. §§ 3.303, 3.304. The Board finally acknowledges that a private physician attempted to relate the Veteran's current lumbosacral spine disability to active service in an October 2021 "Independent Medical Evaluation." A detailed review of this opinion shows that it is not probative on the issue of whether a lumbosacral spine disability is related to active service. This physician opined that it was as likely as not that the Veteran's lumbosacral spine disability is related directly to active service. The rationale for this opinion was that the Veteran's service-connected PTSD led her to develop obesity when then led her to develop lumbosacral spine problems. The Board notes that service connection is not in effect for obesity. Thus, the Board finds that, on remand, another opinion should be obtained which addresses whether the Veteran's lumbosacral spine disability is related directly to active service. Id. 2. Entitlement to service connection for a right shoulder disability is remanded. The Veteran finally contends that she incurred a right shoulder disability during active service and experienced continuous post-service disability. The record evidence shows that she has been diagnosed as having and treated for a variety of right shoulder disabilities, to include right shoulder impingement, acromioclavicular (AC) joint pain, and right shoulder pain, in recent years. To date, however, the AOJ has not scheduled the Veteran for examination to address the contended etiological relationship between a right shoulder disability and active service. The Board notes in this regard that the threshold for providing Veterans with examinations is a low one. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Thus, the Board finds that, on remand, an examination should be provided which addresses this matter. The matters are REMANDED for the following action: 1. Conduct any appropriate development to obtain the Veteran's updated treatment records. 2. Forward the claims file to a clinician for an opinion concerning the nature and etiology of the Veteran's lumbosacral spine. The Veteran does not need to report for examination. Based on a review of the claims file, the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a lumbosacral spine disability is related to active service. The clinician next is asked to state whether a service-connected disability caused or aggravated a lumbosacral spine disability. A rationale must be provided for any opinion(s) expressed. 3. Schedule the Veteran for examination to determine the nature and etiology of her claimed right shoulder disability. The claims file should be provided for review. Based on a review of the claims file and the results of the Veteran's examination, the clinician is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a right shoulder disability, if diagnosed, is related to active service. The clinician next is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's complaints of right shoulder pain result in functional impairment. A rationale must be provided for any opinion(s) expressed. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael T. Osborne, 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.