Citation Nr: 21071240 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 15-01 689A DATE: November 30, 2021 ORDER Service connection for diabetes mellitus, type II, to include as due to exposure to contaminated water at Camp Lejeune; and/or as secondary to service-connected bilateral knee disability, lumbar spine disability, or psychiatric disorder, to include obesity as an intermediate step, is denied. REMANDED Service connection for degenerative arthritis of the cervical spine, to include as due to contaminated water at Camp Lejeune; and/or as secondary to service-connected bilateral knee disability, lumbar spine disability, or psychiatric disorder, to include obesity as an intermediate step, is remanded. FINDING OF FACT The Veteran's type II diabetes mellitus is not shown as chronic in service and did not manifest to a compensable degree within the first post-service year. It is not etiologically related to exposure to contaminated water at Camp Lejeune, is not secondary to service-connected disability, and service-connected disabilities did not cause the Veteran to become obese such that his obesity caused or aggravated his diabetes. CONCLUSION OF LAW The criteria for service connection for diabetes mellitus, to include as secondary to service-connected disability, or to obesity, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Marine Corps from April 1975 until his honorable discharge in July 1977, including service at Camp Lejeune, North Carolina. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 decision by the Louisville, Kentucky, Regional Office of the United States Department of Veterans Affairs (VA), which, among other claims, denied service connection for "arthritis" and "diabetes." Relevant here, in the Board's prior May 2021 Remand Order, it recharacterized the Veteran's claim of arthritis as one for cervical spine arthritis. In July 2018, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge (VLJ). In May 2021, the Board remanded the above claims in order to obtain additional opinions as to the etiology of the Veteran's disabilities. The case now returns to the Board for adjudication. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). This case involves multiple legal theories of service connection. Direct Service Connection Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. Presumptive Service Connection Chronic diseases In addition, service connection may be established on a presumptive basis for certain "chronic diseases"to include diabetes mellitusthat manifest in service or to a degree of 10 percent within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The term "chronic disease" refers to those diseases in 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a). "For the showing of chronic disease in service[,] there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word 'Chronic.' " 38 C.F.R. § 3.303(b). Where a chronic disease is shown in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In cases where a chronic disease is "shown as such in service," the Veteran is "relieved of the requirement to show a causal relationship between the condition in service and the condition for which service-connected disability compensation is sought." Walker, 708 F.3d at 1336. In other words, "there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. Where the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Id. Continuity of symptomatology is established if a claimant demonstrates that a condition was "noted" during service or during the presumptive period, there is evidence of post-service continuity of the same symptoms, and there is evidence of a nexus between the present disability and those symptoms. 38 C.F.R. § 3.303(b). A condition is "noted" where evidence is "indicative of but not dispositive of a chronic disease." Walker, 708 F.3d at 1336. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed. Id. at 1339. Secondary Service Connection Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability exists, (2) the veteran has a service-connected disability; and (3) the current disability was either (a) proximately due to or the result of; or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Where aggravation is the relied upon theory, compensation may only be provided to that degree over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen, 7 Vet. App. at 448. Service Connection Based on Obesity Obesity cannot qualify as an in-service event because it occurs over time and is based on various external and internal factors as opposed to a discrete incident or occurrence or a series of discrete incidents or occurrences. VAOPGCPREC 1-17. VA General Counsel precedential opinions are binding on the Board. 38 U.S.C. § 7104(c); 38 C.F.R. § 14.507. On January 6, 2017, the General Counsel issued a precedential opinion stating that obesity could be an "intermediate step" between a service-connected disability and a current disability, thus satisfying the causal link between the two. VAOPGCPREC 1-17. In such cases where the issue is raised, the adjudicator should resolve three issues: (1) whether the service-connected disability caused the veteran to become obese; (2) if so, whether the obesity was a substantial factor in causing the current disability; and (3) whether the current disability would not have occurred but for the obesity caused by the service-connected disability. VAOPGCPREC 1-17. The Court of Appeals for Veterans Claims held that proper interpretation of VA General Counsel Opinion 1-17 requires consideration of both proximate causation and aggravation in its analytical framework. Walsh v. Wilkie, 32 Vet. App. 300 (2020). That is, (1) whether the service-connected disability caused the veteran to become obese or aggravated the veteran's obesity; if so, (2) whether such obesity or aggravation thereof was a substantial factor in causing the current disability; and, if so, (3) whether the current disability would not have occurred but for such obesity or aggravation thereof. If these questions are answered in the affirmative, then the current disability may be service connected on a secondary basis. Presumptive Service Connection Camp Lejeune For purposes of service connection, if a veteran was exposed to contaminated water at United States Marine Corps Base Camp Lejeune between August 1, 1953, and December 31, 1987, then VA presumes the development of certain diseases is due to that exposure. 38 C.F.R. §§ 3.307, 3.309(f). Contaminants include trichloroethylene (TCE), perchloroethylene (PCE), benzene, and vinyl chloride found in the on-base water supply systems. 38 C.F.R. § 3.307(a)(7)(i). Limitations were put in place describing the minimum qualifications for this presumption to apply. VA regulation 38 C.F.R. § 3.307(a)(7)(iii) provides that a veteran, or former reservist or member of the National Guard, who had no less than 30 days of service (consecutive or nonconsecutive) at Camp Lejeune during the period beginning on August 1, 1953, and ending on December 31, 1987, shall be presumed to have been exposed during such service to the contaminants in the water supply, unless there is affirmative evidence to establish that the individual was not exposed to contaminants in the water supply during that service. The specified diseases that are deemed to be associated with exposure to contaminated water at Camp Lejeune are: Kidney cancer Multiple myeloma Liver cancer Parkinson's disease Non-Hodgkin's lymphoma Bladder cancer Adult leukemia Aplastic anemia and other myelodysplastic syndromes 38 C.F.R. § 3.309(f). If a listed disease develops, it must be severe enough to warrant a 10-percent disability rating for the presumption to apply. 38 C.F.R. § 3.307(a)(7)(ii). If the Veteran meets the criteria for presumptive service connection, then this satisfies the second and third elements of the direct service-connection test, alleviating the need for direct evidence to establish these elements. Analysis Service connection for diabetes mellitus, type II The Veteran asserts numerous theories of entitlement for service connection for diabetes mellitus, type II (hereinafter referred to a "diabetes"). First, there is an assertion that his diabetes was caused by contaminated water while stationed at Camp Lejeune, North Carolina (presumptively or on a direct basis). Second, he asserts his diabetes is a chronic condition associated with his military service (presumptively or on a direct basis). Third, he asserts his diabetes was caused or aggravated by his service-connected bilateral knee disability, lumbar spine disability, and/or psychiatric disability. Fourth, he asserts his service-connected bilateral knee disability, lumbar spine disability, and/or psychiatric disability caused his obesity, which in turn caused his diabetes. For the reasons that follow, the Board finds the Veteran is not entitled to service connection on any of these theories. For each theory of service connection addressed in this decision, the Veteran must have a "current disability"; otherwise, there is nothing for which to grant service connection. The requirement for a veteran to have a "current disability" is satisfied when he or she has a disability (1) at the time a claim for VA disability compensation is filed or (2) has a disability during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran asserts he had a diagnosis of diabetes in the 1980s. The Board finds the Veteran was medically diagnosed with diabetes in 2006 based on his medical records. See October 2006 VA Nursing Telephone Encounter Note (noting no prior history of diabetes); November 2006 VA Nutrition Consult (noting new diagnosis of diabetes); December 2020 VA Examination (confirming diagnosis of diabetes in 2006). In addition, since 2006, the Veteran was continuously treated for diabetes. Therefore, he has a current disability for purposes of service connection. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Therefore, the first element of service connection, a current disability, is satisfied for each theory of service connection. Presumptive Service Connection Camp Lejeune The Board first addresses the theory of entitlement to presumptive service connection based on presumed exposure to contained water at Camp Lejuene. According to his military records, the Veteran served at Camp Lejeune from approximately August 1975 to October 1975 and subsequent service in February 1977 until his discharge in July 1977. His service during each period was consecutive. As such, the Veteran is presumed to have been exposed during such service to the contaminants in the water supply, and the Board finds no affirmative evidence to the contrary. 38 C.F.R. § 3.307(a)(7)(iii). Diabetes, however, is not a listed disease associated with contaminated water at Camp Lejeune. Therefore, presumptive service connection is not warranted. 38 C.F.R. § 3.309(f). Even though a presumptive service connection is precluded for the Veteran's diabetes, a grant of service connection may be made on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Presumptive service connection Chronic disease Diabetes is a chronic disease and may be presumptively service connected if it manifested during the Veteran's active service or within one year of his separation from active service. 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). The Veteran separated from service in July 1977. His diabetes was not diagnosed until the 1980s, according to his lay statement, and his medical records indicate a diagnosis in 2006. A review of his in-service treatment records and post-service medical records does not reveal a diagnosis of diabetes while in service or within one year following his discharge from active service. The provisions of law regarding continuity of symptomatology are not for application. The Veteran's in-service medical records and post-service medical records do not "note" symptomatology that may reasonably be associated with diabetes during service or within one year following separation from active military service. Therefore, the Veteran is not entitled to presumptive service connection for diabetes as a chronic disease. Direct service connection First element: A current disability For the reasons already discussed, the Veteran has a current diagnosis of diabetes. Therefore, the first element is satisfied. Second element: An in-service event, injury, or illness, or aggravation thereof The record, rather than the Veteran, reasonably asserts exposure to contaminated water at Camp Lejeune as an in-service event. Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (Board is required to consider theories of entitlement to benefits that are either raised by the claimant or reasonably raised by the record). For the reasons already discussed, the Veteran is presumed to have been exposed to contaminated water at Camp Lejeune. Therefore, the second element is satisfied. Third element: A causal link The evidence of record weighs against finding that the Veteran's diabetes was due to his exposure to contaminated water at Camp Lejeune. In a December 2020 VA addendum opinion and a May 2021 addendum opinion, a VA examiner opined that the Veteran's diabetes was less likely than not caused by his exposure to contaminated water at Camp Lejeune in service. The examiner reasoned that, based on her review of standard medical literature and Up-to-Date, an online medical reference, contaminated water at Camp Lejeune is not a risk factor associated with diabetes. Absent evidence to the contrary, the Board finds the December 2020 and May 2021 VA examiner's respective medical opinions the most credible and probative evidence of record addressing whether the Veteran's diabetes was caused by his exposure to contaminated water at Camp Lejeune. The examiners relied on accurate facts, considered the Veteran's relevant medical records, medical history, and lay statements, and provided well-reasoned medical judgments that connected the facts to the conclusions. Simply put, available medical evidence and knowledge does not link contaminated water at Camp Lejeune with diabetes. Therefore, the Veteran's diabetes is not due to his exposure to contaminated water. Although short, the analysis offered is sufficient. See Monzingo v. Shinseki, 26 Vet. App. 97, 10607 (2012) (VA examiners are presumed, absent clear evidence to the contrary, "to remain up-to-date on medical knowledge and current medical studies" and failure to cite any studies is not a basis for finding the examination report inadequate). Therefore, the Board concludes that the evidence is against finding a causal link between the Veteran's exposure to contaminated water at Camp Lejeune and his diabetes. Thus, the third element is not satisfied. Accordingly, service connection for diabetes on a direct basis is not warranted. Secondary service connection First element: A current disability As already discussed, the Veteran has a current diagnosis of diabetes. Therefore, the first element is satisfied. Second element: A current service-connected disability As to the second element, a current service-connected disability, the Veteran is currently service-connected for a right knee disability, left knee disability, lumbar spine disability, and depressive disorder, which are the bases of his claim for secondary service connection. The Veteran has additional service-connected disabilities, but he does not argue that his other service-connected disabilities are the basis for his secondary-service-connection claim, nor does a reasonable review of the record raise such claims. Therefore, the Board finds the second element is satisfied. Third element: A causal link In association with the Veteran's claim for secondary service connection, he asserts that due to the above-cited service-connected disabilities, he has been unable to engage in proper fitness routines, which has subsequently caused him to gain weight to the point of obesity. Consequently, he asserts his diabetes was caused by or aggravated by his weight gain due to his above-cited service-connected disabilities. The Board concludes the evidence weighs against finding that the Veteran's diabetes was caused by or aggravated by one or more of his service-connected disabilities cited above, to include obesity as an intermediate step. Causation "Proximate cause" is defined as "[t]hat which, in a natural and continuous sequence, unbroken by any efficient intervening cause, produces injury, and without which the result would not have occurred." Black's Law Dictionary 1225 (6th ed. 1990); VAOPGCPREC 6-03 (adopting this definition). When there are potentially multiple causes of a harm, an action is considered to be a proximate cause of the harm if it is a substantial factor in bringing about the harm and the harm would not have occurred but for the action. VAOPGCPREC 6-03. The December 2020 VA examiner opined that the Veteran's diabetes was less likely than not caused by his service-connected right knee disability, left knee disability, lumbar spine disability, or psychiatric disorder. The December 2020 VA examiner conducted an examination of the Veteran, which included consideration of the Veteran's lay statements to her at the time of the examination. This is the extent of the examiner's rationale, and the Board finds it is not probative as it does not discuss any pertinent facts. LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (holding a medical report may be rejected as incompetent medical evidence when it is simply the recorded information of the claimant "unenhanced by any additional medical comment by [a] medical examiner.") Following the Board's May 2021 Remand Order, the VA Regional Office obtained an addendum opinion from the same examiner addressing the theory of secondary causation. In an August 2021 addendum opinion, the examiner opined that the Veteran's diabetes was less likely than not caused by his service-connected right knee disability, left knee disability, lumbar spine disability, or psychiatric disorder. The examiner indicated review of the Veteran's medical records, his lay statements, and the available evidence, to include a previous in-person examination. The examiner cited her reasoning contained in her May 2021 opinion (a prior addendum opinion) in which she stated that, based on her review of standard medical textbooks and Up-to-Date medical literature, diabetes and the Veteran's service-connected bilateral knee disabilities, lumbar spine disability, and psychiatric disorder are pathophysiologically different conditions. "Pathophysiology" is defined as the "physiology of disordered function." Dorland's Illustrated Medical Dictionary 1397 (32d ed. 2012). "Physiology" is defined as "(1) the science of the function of the living organism and its parts, and of the physical and chemical factors and processes involved. (2) the basic processes underlying the functioning of a species or class of organism, or any of its parts or processes." Id. at 1444. "Etiology" is defined as "(1) the study or theory of the factors that cause disease and the method of their introduction to the host. (2) the causes or origin of a disease or disorder." Id. at 652. The Board finds the examiner's opinion the most credible and probative evidence of record addressing whether the Veteran's diabetes was caused by his service-connected right knee disability, left knee disability, lumbar spine disability, or psychiatric disorder. The examiner explained that she arrived at this conclusion following consideration of medical textbooks and literature, and after consideration of evidence of record. Where there is no pathophysiologic relation between the Veteran's diabetes and his cited service-connected disabilities, a causal link does not exist. Therefore, secondary service connection on the theory of causation is not warranted. Although short, the Board is able to interpret this opinion as providing a sufficient link between the facts and ultimate conclusion. McCray v. Wilkie, 31 Vet. App. 243, 257 (2019) (Board is capable of interpreting medical opinion evidence) (citing Harvey v. Shulkin, 30 Vet. App. 10, 20 (2018)). Aggravation "Aggravation" in the context of secondary service connection is demonstrated when there is "[a]ny increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease." 38 C.F.R. § 3.310(b). Similar to the discussion above as to secondary causation, the December 2020 VA examiner opined that the Veteran's diabetes was less likely than not aggravated by his service-connected right knee disability, left knee disability, lumbar spine disability, or psychiatric disorder. But the examiner's opinion is also deficient for the same reasons cited above in the discussion of secondary causation. Thus, the Board finds it is not probative as it does not discuss any pertinent facts. LeShore, 8 Vet. App. at 409. In a May 2021 addendum opinion, the examiner opined that the Veteran's diabetes was less likely than not aggravated by his service-connected right knee disability, left knee disability, lumbar spine disability, or psychiatric disorder. The examiner's reasoning consisted of the same rationale discussed above in the analysis of secondary causation. The Board finds the examiner's opinion the most credible and probative evidence of record addressing whether the Veteran's diabetes was aggravated by his cited service-connected disabilities. The examiner explained that she arrived at this conclusion following consideration of medical textbooks and literature, and after consideration of evidence of record. Where there is no pathophysiologic relation between the Veteran's diabetes and his cited service-connected disabilities, a link does not exist to find aggravation. Therefore, secondary service connection on the theory of aggravated is not warranted. Obesity as an intermediate step The December 2020 VA examiner opined that the Veteran's diabetes was less likely than not caused by or aggravated beyond its natural progression by his right knee disability, left knee disability, lumbar spine disability, or psychiatric disorder. The examiner considered that the Veteran had an active post-service employment history and only began a sedentary position in 2008 based on his lay statements. The examiner accepted the Veteran's lay statement that he had a diagnosis of diabetes in the 1980s. After considering the Veteran's statements and medical history, the examiner concluded that the Veteran's diabetes was diagnosed before his obesity diagnosis, as documented in a 1997 VA medical record, thus making it less likely that his current service-connected disabilities led to his obesity and subsequently caused or aggravated his diabetes. She noted the Veteran's diabetes is currently controlled by medication and found no evidence suggesting aggravation beyond the normal progression of the disease. In a May 2021 addendum opinion, the examiner continued to opine that it was less likely than not that the Veteran's service-connected right knee disability, left knee disability, lumbar spine disability, or psychiatric disorder caused his obesity and, in turn, caused or aggravated his diabetes. The examiner noted review of multiple medical records cited within the Board's May 2021 Remand Order addressing the Veteran's weight between 1997 and 2006. In addition, the examiner reviewed previous examinations of record, including the Veteran' lay statements therein, and medical literature from Up-to-Date regarding the multifactorial risk factors for the development of diabetes, including genetic susceptibility, and the Veteran's ethnicity. The examiner also reviewed standard medical textbooks and Up-to-Date medical literature stating that "obesity itself is multifactorial, including advancing age [and] overeating. As a man ages, there is natural age-related decline in serum testosterone that is associated with increase in fat mass and decrease in muscle mass leading to obesity." Again, the examiner accepted the Veteran's statement as to a diagnosis of diabetes in 1980 as true. In light of the evidence of record and the cited medical literature review, the examiner found the Veteran's diabetes preceded his first diagnosis of obesity in 1997. Thus, his current service-connected disabilities did not cause his obesity, and his obesity did not cause or aggravate his diabetes. She noted the Veteran's diabetes is currently controlled by medication and found no evidence suggesting aggravation beyond the normal progression of the disease. The Board finds the examiners' opinions, when read together, the most credible and probative evidence of record addressing whether the Veteran's diabetes was caused by his service-connected right knee disability, left knee disability, lumbar spine disability, or psychiatric disorder. The examiner considered the Veteran's lay statements, his medical records, and the evidence of record. Based on her review of medical literature, she found that the Veteran's report of diabetes in the 1980s credible and, therefore, the initial diagnosis of his obesity in 1997 could not have led to his diabetes as his diabetes preceded his obesity. Accordingly, service connection for diabetes as due to obesity caused by service-connected right knee disability, left knee disability, lumbar spine disability, or psychiatric disorder is not warranted. REASONS FOR REMAND 1. Service connection for a cervical spine disability is remanded. The Board remanded this claim to the VA Regional Office in February 2019, November 2020, and May 2021. There has yet to be substantial compliance with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). In particular, the addendum opinions obtained by the VA Regional Office are insufficient at this time because they contain no rationale that clearly connects the facts relied on by the examiner to her ultimate opinions in the matter. Instead, the examiner only states the evidence she considered and then says that the Veteran's cervical spine disability is less likely than not related to active service, his service-connected disabilities, and is not caused by obesity. In short, there is no rationale, just statements and conclusion. LeShore, 8 Vet. App. at 409 (holding a medical report may be rejected as incompetent medical evidence when it is simply the recorded information of the claimant "unenhanced by any additional medical comment by [a] medical examiner."); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("It is the fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion."). Therefore, remand is required for another addendum opinion as there remains in sufficient evidence in the record on which to grant service connection under any of the Veteran's theories. Accordingly, the matter is REMANDED for the following actions: 1. Obtain any of the Veteran's outstanding VA medical records and associate them with the claims file. 2. After any additional records are associated with the claims file, obtain an addendum opinion from the December 2020/May 2021/August 2021 VA examiner, or another appropriately qualified clinician if that examiner is unavailable, to provide an opinion addressing the onset and etiology of the Veteran's cervical spine disability, to include degenerative arthritis and intervertebral disc syndrome. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. If the examiner decides an examination is necessary, then one shall be provided. The examiner is asked to provide an opinion regarding: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's cervical spine disability had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include as due to (1) in-service physical training; and (2) contaminated water at Camp Lejeune, North Carolina. (The Board realizes arthritis is not a condition subject to presumptive service connection with exposure to contaminated water at Camp Lejeune. Instead, the Board is requesting an opinion on whether the Veteran's exposure to contaminated water at Camp Lejeune is causally linked to his arthritis under a theory of direct service connection.) A full rationale must be provided, do not simply list evidence considered and facts found. (b.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran's cervical spine disability was caused by (proximately due to or as the result of) his service-connected (i) right knee disability, (ii) left knee disability, (iii) lumbar spine disability, or (iv) psychiatric disability. A full rationale must be provided, do not simply list evidence considered and facts found. (c.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's cervical spine disability was aggravated by his service-connected (i) right knee disability, (ii) left knee disability, (iii) lumbar spine disability, or (iv) psychiatric disability. The examiner is advised "aggravation" means any increase in the severity of the underlying disability beyond its natural progression. A full rationale must be provided, do not simply list evidence considered and facts found. In rendering his or her opinion as to the issue of secondary service connection, the examiner must opine on the following in relation to obesity as an intermediate step to secondary service connection: (a.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's service-connected (i) right knee disability, (ii) left knee disability, (iii) lumbar spine disability, or (iv) psychiatric disability caused the Veteran to become obese? A full rationale must be provided, do not simply list evidence considered and facts found. (b.) If the Veteran's service-connected (i) right knee disability, (ii) left knee disability, (iii) lumbar spine disability, or (iv) psychiatric disability caused him to become obese, is it at least as likely as not (a 50 percent probability or more) that his obesity was a substantial factor in causing his cervical spine disability? A full rationale must be provided, do not simply list evidence considered and facts found. (c.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran's cervical spine disability would not have occurred but for the obesity caused by his service-connected (i) right knee disability, (ii) left knee disability, (iii) lumbar spine disability, or (iv) psychiatric disability? A full rationale must be provided, do not simply list evidence considered and facts found. The examiner is reminded to consider the Veteran's lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertion of a cervical spine disability in service or the assertion that the Veteran's service-connected disabilities led to his cervical spine disability. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, is an insufficient rationale. The examiner is informed that the absence of contemporaneous service treatment records or medical records in general, standing alone, without explaining why such evidence is significant, is an insufficient rationale. If the examiner relies on medical treatises, the examiner should identify the treatises. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 3. The Regional Office must ensure substantial compliance with the foregoing remand directives, particularly ensuring sufficient rationales have been provided by the examiner. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, 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.