Citation Nr: 21075352 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 11-03 500 DATE: December 20, 2021 REMANDED Entitlement to service connection for a right knee condition, to include as secondary to service-connected conditions, is remanded. Entitlement to service connection for a left knee condition, to include as secondary to service-connected conditions, is remanded. Entitlement to service connection for a cervical spine condition, to include as secondary to service-connected conditions, is remanded. Entitlement to service connection for hypertension, to include as due to herbicide exposure and as secondary to service-connected conditions, is remanded. Entitlement to service connection for diverticulitis, to include as due to herbicide exposure and as secondary to service-connected conditions, is remanded. Entitlement to service connection for hemorrhoids, to include as secondary to service-connected conditions, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1968 to August 1970, to include service in the Republic of Vietnam (RVN). These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2010 rating decision issued by a Department of Veterans Affairs (VA) regional office. These matters were previously remanded by the Board in May 2019 and May 2021. In February 2019, the Veteran testified via video conference before the undersigned Veterans Law Judge (VLJ). A copy of hearing transcript has been associated with the claims file. See February 2019 Board Hearing Transcript, received April 2019. 1. Entitlement to service connection for a right knee condition, to include as secondary to service-connected conditions, is remanded. 2. Entitlement to service connection for a left knee condition, to include as secondary to service-connected conditions, is remanded. The Board regrets the delay associated with this remand, particularly as these matters are the subject of two prior remands. However, based on a review of the evidence of record, the Board finds that another remand is necessary as the Agency of Original Jurisdiction (AOJ) has not substantially complied with the May 2021 remand directives. See Stegall v. West, 11 Vet. App. 258, 271 (1998). Specifically, in May 2021, the Board instructed the AOJ to obtain opinions regarding the etiology of the Veteran's claimed bilateral knee conditions. As part of these opinions, the examiner was instructed to address whether the Veteran's right knee conditions were at least as likely as not related to his active duty service or a service-connected disability. In June 2021, a VA opinion was obtained in which the examiner stated that the Veteran's bilateral knee osteoarthritis and bilateral patellofemoral pain syndrome were not diagnosed during service and that medical literature supported that such conditions were considered part of the normal aging process. However, the examiner declined to offer an opinion with respect to the Veteran's diagnosed right knee Osgood-Schlatter's disease, stating that as the Veteran was not diagnosed with such condition prior to service, during service, or within a year following separation from service, any such opinion would be for educational purposes only. Additionally, the examiner did not address whether the Veteran's diagnosed knee conditions were related to a service-connected disability. See June 2021 Knee Addendum Disability Benefits Questionnaire (DBQ). As the Board cannot find substantial compliance with the May 2021 remand directives, a remand is necessary to allow the AOJ to obtain an opinion regarding the nature and etiology of the Veteran's claimed bilateral knee conditions. See Stegall v. West, supra. Even if the Board could find substantial compliance with the May 2021 remand directives, a remand would be warranted nonetheless to obtain adequate opinions regarding the nature and etiology of the Veteran's claimed bilateral knee conditions. As discussed above, a VA opinion was obtained in June 2021, in which the examiner stated that the Veteran's bilateral knee osteoarthritis and bilateral patellofemoral pain syndrome were not diagnosed during service and that medical literature supported that such conditions were considered part of the normal aging process. See id. However, while an opinion as to whether the Veteran's bilateral knee conditions are related to his active duty service may be inferred by the examiner's statement, no actual opinion was provided. See id. Additionally, with respect to the Veteran's pre-existing left knee Osgood-Schlatter's disease, the examiner opined that such condition was clearly and unmistakable not aggravated by service. In support of this opinion, the examiner stated that the pre-existing condition was acute and transitory, and resolved with proper treatment. See id. However, in a November 2019 VA examination, the Veteran was diagnosed with bilateral chronic Osgood-Schlatter's disease. See November 2019 VA Knee and Lower Leg Conditions DBQ. As such, the June 2021 opinion appears to be based on an inaccurate factual premise. See Reonal v. Brown, 4 Vet. App. 458 (1993). Further, an opinion is inadequate when, as indicated here, the examiner does not consider the Veteran's prior medical history. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). For these reasons, the Board finds the June 2021 opinion to be inadequate for adjudication purposes and, as such, a remand is necessary to obtain adequate opinions regarding the nature and etiology of the Veteran's claimed bilateral knee conditions. See Barr v. Nicholson, 21 Vet. App. 120, 123 (2007). Lastly, the Board finds that this issue poses a medical problem of such obscurity or complexity that an advisory opinion from an independent medical expert (IME) is required. See 38 U.S.C. § 5109; 38 C.F.R. § 3.328. Specifically, multiple VA opinions have been unable to adequately answer the question of the nature and etiology of the Veteran's claimed bilateral knee conditions. The AOJ must follow its established procedures for requesting an advisory opinion furnished by a medical school, university, or clinic on remand. 3. Entitlement to service connection for a cervical spine condition, to include as secondary to service-connected conditions, is remanded. The Board regrets the delay associated with this remand, particularly as this matter is the subject of two prior remands. However, based on a review of the evidence of record, the Board finds that a remand is necessary to allow the AOJ to obtain an adequate opinion regarding the nature and etiology of the Veteran's claimed cervical spine condition. In November 2019, the Veteran underwent a VA examination in which the examiner noted diagnoses of cervical degenerative changes and cervical muscle spasm. Ultimately, the examiner opined that the Veteran's cervical spine conditions were less likely than not related to his active duty service. In support of this opinion, the examiner noted that the Veteran's muscle spasm was not diagnosed until 2010, that the Veteran's service records were silent regarding any diagnosis or symptoms of the Veteran's cervical spine conditions, and there was no evidence of any manifestation or diagnosis of his cervical spine conditions within a year following separation from active service. See November 2019 VA Neck Conditions DBQ; November 2019 VA Neck Medical Opinion DBQ. In other words, in opining that the Veteran's cervical spine conditions were less likely than not related to his active duty service, the examiner relied solely on the absence of in-service documentation of such conditions. However, the lack of documented complaints, standing alone, is not an adequate basis for a negative opinion. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). Further, while certain chronic diseases, including arthritis, are presumptively related to service if they manifest within one year following separation from service, there is no requirement that a condition manifest within one year following separation for such condition to be related to service. See 38 C.F.R. §§ 3.307, 3.309. As such, the examiner appears to have used the wrong standard in determining whether the Veteran's diagnosed cervical spine conditions are related to service. In June 2021, a VA opinion was obtained in which the examiner opined that the Veteran's diagnosed cervical spine conditions were less likely than not caused by or aggravated by his service-connected lower back condition, peripheral vascular disease of the bilateral lower extremities, or bilateral pes planus. In support of this opinion, the examiner stated that there was no medical literature to support the contention that the Veteran's cervical degenerative disc disease could be caused or aggravated by such service-connected conditions. Additionally, the examiner stated that the Veteran's cervical spine conditions were not pathophysiologically or anatomically related to his service-connected conditions. See June 2021 VA Neck Medical Opinion However, the examiner did not cite any medical literature or otherwise elaborate in support of their conclusion that the Veteran's cervical spine conditions were not pathophysiologically or anatomically related to, and his cervical degenerative disc disease could not be caused or aggravated by, his service-connected conditions. See id. As such, the Board finds the opinion to be conclusory and, therefore, inadequate. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). For these reasons, the Board finds the November 2019 and June 2021 VA opinions to be inadequate for adjudication purposes. Therefore, a remand is necessary to allow the AOJ to obtain an adequate opinion regarding the nature and etiology of the Veteran's claimed cervical spine conditions. See Barr v. Nicholson, supra. Lastly, the Board finds that this issue poses a medical problem of such obscurity or complexity that an advisory opinion from an independent medical expert (IME) is required. See 38 U.S.C. § 5109; 38 C.F.R. § 3.328. Specifically, multiple VA opinions have been unable to adequately answer the question of the nature and etiology of the Veteran's claimed cervical spine conditions. The AOJ must follow its established procedures for requesting an advisory opinion furnished by a medical school, university, or clinic on remand. 4. Entitlement to service connection for hypertension, to include as due to herbicide exposure and as secondary to service-connected conditions, is remanded. The Board regrets the delay associated with this remand, particularly as this matter is the subject of two prior remands. However, based on a review of the evidence of record, the Board finds that a remand is necessary to allow the AOJ to obtain an adequate opinion regarding the nature and etiology of the Veteran's hypertension. In January 2021, a VA opinion was obtained in which the examiner opined that the Veteran's hypertension was less likely than not related to his active duty service. In support of this opinion, the examiner stated that there was no evidence of hypertension in the Veteran's service treatment records (STRs) and that there was no evidence in medical literature of an etiological link between hypertension and herbicide exposure. See January 2021 VA Hypertension Medical Opinion DBQ. However, the Veteran's separation examination documented elevated blood pressure. See STR-Medical. Additionally, in 2018 the National Academy of Sciences, Engineering, and Medicine (NAS) published updated information about the relationship between a person's exposure to Agent Orange and subsequent development of hypertension. In this update, of which the Board has constructive possession, NAS upgraded the relationship between hypertension and Agent Orange exposure from "limited or suggestive" to "sufficient," indicating that "there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide exposure. See National Academies of Sciences, Engineering, and Medicine 2018, Veterans and Agent Orange: Update 11 (2018); Euzebio v. McDonough, 989 F.3d 1305 (Fed. Cir. 2021). As such, with respect to service connection on a direct basis, the January 2021 opinion appears to be based, in part, on an inaccurate factual basis. See Reonal v. Brown, 4 Vet. App. 468 (1993). The January 2021 examiner also opined that the Veteran's hypertension was less likely than not caused or aggravated by a service-connected condition. In support of this opinion, the examiner stated that there was no evidence of hypertension secondary to a service-connected condition in medical literature, and no evidence of aggravation of hypertension by a service-connected condition as they are not etiologically related. See January 2021 VA Hypertension Medical Opinion DBQ. However, the examiner did not cite any medical literature or otherwise elaborate in support of their conclusion that the Veteran's hypertension was not caused or aggravated by a service-connected condition. See id. As such, the Board finds the opinion to be conclusory and, therefore, inadequate. See Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. In June 2021, a VA opinion was obtained in which the examiner opined that the Veteran's hypertension was less likely than not related to his active duty service. In support of this opinion, the examiner stated that there was no evidence of hypertension in service or high blood pressure on the separation exam that would suggest the beginning of high blood pressure. See June 2021 VA Hypertension Medical Opinion DBQ. However, as discussed above, the Veteran's separation examination documented elevated blood pressure. See STR-Medical. As such, the June 2021 opinion appears to be based, in part, on an inaccurate factual basis. See Reonal v. Brown, supra. Additionally, an opinion is inadequate when, as suggested here, an examiner does not consider the Veteran's prior medical history. See Stefl v. Nicholson, supra. Moreover, the June 2021 examiner did not address the Veteran's conceded herbicide exposure, nor did the examiner address whether the Veteran's hypertension was caused or aggravated by a service-connected condition. Therefore, the June 2021 opinion cannot be deemed adequate to the extent it did not discuss such. For these reasons, the Board finds the January 2021 and June 2021 VA opinions to be inadequate for adjudication purposes. Therefore, a remand is necessary to allow the AOJ to obtain an adequate opinion regarding the nature and etiology of the Veteran's claimed cervical spine conditions. See Barr v. Nicholson, supra. Lastly, the Board finds that this issue poses a medical problem of such obscurity or complexity that an advisory opinion from an independent medical expert (IME) is required. See 38 U.S.C. § 5109; 38 C.F.R. § 3.328. Specifically, multiple VA opinions have been unable to adequately answer the question of the nature and etiology of the Veteran's claimed cervical spine conditions. The AOJ must follow its established procedures for requesting an advisory opinion furnished by a medical school, university, or clinic on remand. 5. Entitlement to service connection for diverticulitis, to include as due to herbicide exposure and as secondary to service-connected conditions, is remanded. The Board regrets the delay associated with this remand, particularly as this matter is the subject of two prior remands. However, based on a review of the evidence of record, the Board finds that a remand is necessary as the AOJ has not substantially complied with the May 2021 remand directives. See Stegall v. West, supra. In May 2021, the Board instructed the AOJ to obtain an opinion regarding the etiology of the Veteran's diverticulitis. As part of this opinion, the Board instructed the examiner to opine as to whether it was at least as likely as not that the Veteran's diverticulitis was caused or aggravated by his service-connected disabilities, to include medications taken for such; the examiner was instructed to specifically address the use of NSAIDs to treat his service-connected disabilities. In June 2021, a VA opinion was obtained. However, while the examiner noted that the use of NSAIDs was a risk factor for the development of diverticulitis, no opinion was provided as to whether the Veteran's hemorrhoids were caused by his service-connected conditions, to include medications taken for such. See June 2021 VA Diverticulitis Medical Opinion DBQ. As the Board cannot find substantial compliance with the May 2021 remand directives, a remand is necessary to allow the AOJ to obtain an opinion regarding the etiology of the Veteran's diverticulitis. See Stegall v. West, supra. Even if the Board could find substantial compliance with the May 2021 remand directives, a remand would nonetheless be necessary to allow the AOJ to obtain an adequate opinion regarding the etiology of the Veteran's diverticulitis. In January 2021, a VA opinion was obtained in which the examiner opined that the Veteran's diverticulitis was less likely than due to or the result of his service-connected prostate cancer or the treatment thereof. In support of this opinion, the examiner noted diverticulitis and prostate cancer are different conditions with different etiologies. See January 2021 VA Diverticulitis Medical Opinion DBQ. However, the examiner did not cite any medical literature or otherwise elaborate in support of their conclusion that diverticulitis is not etiologically related to prostate cancer or the treatment thereof. See id. As such, the Board finds the opinion to be conclusory and, therefore, inadequate. See Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. In February 2021, a VA opinion was obtained in which the examiner opined that the Veteran's diverticulitis was less likely than not related to his active duty service, to include conceded herbicide exposure. In support of this opinion, the examiner noted that diverticulitis's risk factors include aging, obesity, smoking, lack of exercise, high fat or low fiber diet, and medications such as steroids, opioids, and NSAIDs, but it is not related to the Veteran's reported in-service experiences such as heavy lifting and firing. With respect to herbicide exposure, the examiner noted that diverticulitis is not subject to presumptive service connection. See February 2021 VA Diverticulitis Medical Opinion DBQ. However, that diverticulitis is not amongst the conditions for which service connection is available on a presumptive basis does not preclude a finding that the Veteran's diverticulitis is etiologically related to his conceded herbicide exposure. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Stefl v. Nicholson, supra. As the examiner relied exclusively on the presumption in finding that the Veteran's diverticulitis was not etiologically related to his conceded herbicide exposure, the Board finds the opinion to be inadequate with respect to such. For these reasons, the Board finds the January 2021 and February 2021 VA opinions to be inadequate for adjudication purposes. Therefore, a remand is necessary to allow the AOJ to obtain an adequate opinion regarding the etiology of the Veteran's diverticulitis. See Barr v. Nicholson, supra. Lastly, the Board finds that this issue poses a medical problem of such obscurity or complexity that an advisory opinion from an independent medical expert (IME) is required. See 38 U.S.C. § 5109; 38 C.F.R. § 3.328. Specifically, multiple VA opinions have been unable to adequately answer the question of the etiology of the Veteran's hemorrhoids. The AOJ must follow its established procedures for requesting an advisory opinion furnished by a medical school, university, or clinic on remand. 6. Entitlement to service connection for hemorrhoids, to include as secondary to service-connected conditions, is remanded. The Board regrets the delay associated with this remand, particularly as this matter is the subject of two prior remands. However, based on a review of the evidence of record, the Board finds that a remand is necessary as the AOJ has not substantially complied with the May 2021 remand directives. See Stegall v. West, supra. In May 2021, the Board instructed the AOJ to obtain an opinion regarding the etiology of the Veteran's hemorrhoids. As part of this opinion, the Board instructed the examiner to opine as to whether it was at least as likely as not that the Veteran's hemorrhoids were caused or aggravated by his service-connected radiation proctitis or his diverticulitis. In June 2021, a VA opinion was obtained. However, the examiner did not address the Veteran's service-connected radiation proctitis. See June 2021 VA Hemorrhoids Medical Opinion DBQ. As the Board cannot find substantial compliance with the May 2021 remand directives, a remand is necessary to allow the AOJ to obtain an opinion regarding the etiology of the Veteran's hemorrhoids. See Stegall v. West, supra. Even if the Board could find substantial compliance with the May 2021 remand directives, a remand would nonetheless be necessary to allow the AOJ to obtain an adequate opinion regarding the etiology of the Veteran's hemorrhoids. In February 2021, a VA opinion was obtained in which the examiner opined that the Veteran's hemorrhoids were less likely than not related to his active duty service. In support of this opinion, the examiner stated that there was no evidence of hemorrhoids in the Veteran's STRs and there was no evidence in medical literature of heavy lifting as an etiology of hemorrhoids. See February 2021 VA Hemorrhoids Medical Opinion DBQ. However, the examiner did not cite any medical literature or otherwise elaborate in support of their conclusion that hemorrhoids are not etiologically related to heavy lifting. See id. As such, the Board finds the opinion to be conclusory and, therefore, inadequate. See Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. As indicated above, in June 2021 a VA opinion was obtained in which the examiner opined that the Veteran's hemorrhoids were less likely than not caused or aggravated by the Veteran's diverticulitis. In support of this opinion, the examiner stated that there was no pathophysiological relationship between hemorrhoids and diverticulitis and that there was no evidence of aggravation in the Veteran's medical records. See June 2021 VA Hemorrhoids Medical Opinion DBQ. However, the examiner did not cite any medical literature or otherwise elaborate in support of their conclusion that there is no pathophysiological relationship between hemorrhoids and diverticulitis. See id. As such, the Board finds the opinion to be conclusory and, therefore, inadequate. See Stefl v. Nicholson, supra; Nieves-Rodriguez v. Peake, supra. For these reasons, the Board finds the February 2021 and June 2021 VA opinions to be inadequate for adjudication purposes. Therefore, a remand is necessary to allow the AOJ to obtain an adequate opinion regarding the etiology of the Veteran's hemorrhoids. See Barr v. Nicholson, supra. Lastly, the Board finds that this issue poses a medical problem of such obscurity or complexity that an advisory opinion from an independent medical expert (IME) is required. See 38 U.S.C. § 5109; 38 C.F.R. § 3.328. Specifically, multiple VA opinions have been unable to adequately answer the question of the etiology of the Veteran's hemorrhoids. The AOJ must follow its established procedures for requesting an advisory opinion furnished by a medical school, university, or clinic on remand. Accordingly, the matters are REMANDED for the following action: 1. With the Veteran's assistance as appropriate, obtain and associate with the electronic claims file any outstanding pertinent medical records, whether VA or private, to include records relating to treatment at San Juan VA Medical Center from July 2021 to current. Pursuant to 38 C.F.R. § 3.159(e), any efforts to secure these records MUST be documented in the electronic claims file, and the Veteran MUST be informed if any of these records are unable to be secured. 2. After completing the development above, and any additional development warranted by the record, obtain an advisory medical opinion from an appropriate medical expert, pursuant to 38 U.S.C. § 5109 and 38 C.F.R. § 3.328, regarding the nature and etiology of the Veteran's claimed bilateral knee conditions. The AOJ must follow its established procedures for requesting such an advisory opinion. The entire claims file must be provided to, and reviewed by, the physician. If the physician determines it to be necessary, an examination should be scheduled and any indicated tests, studies, or evaluations should be conducted. The physician is asked to: 3. If an examination is conducted, obtain the Veteran's detailed lay history, including onset and progression of symptomatology. 4. For the Veteran's diagnosed Osgood-Schlatter's disease, address the following: i. Does the evidence clearly and unmistakably show that such condition existed prior to service? THE EXAMINER IS SPECIFICALLY ASKED TO ADDRESS THE JUNE 1968 ENLISTMENT EXAMINATION. ii. If such condition did clearly and unmistakably pre-exist the Veteran's service, does the evidence CLEARLY AND UNMISTAKABLY show that the pre-existing condition DID NOT increase in severity beyond the natural progress of the condition (i.e. the condition was not aggravated by service)? 5. If the Veteran's diagnosed Osgood-Schlatter's disease did not clearly and unmistakably pre-exist the Veteran's service, address the following: i. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that it had its onset during, or is otherwise related to, the Veteran's active duty service; ii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition was caused by a service-connected condition; and iii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition underwent an incremental increase (aggravated), regardless of permanence, by a service-connected condition. 6. For each diagnosed knee condition other than Osgood-Schlatter's disease, opine as to: i. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition had its onset during, or is otherwise related to, the Veteran's active duty service; ii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition was caused by a service-connected condition; and iii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition underwent an incremental increase (aggravated), regardless of permanence, by a service-connected condition. 7. In formulating the requested opinions, the physician is asked to consider and specifically address: i. The notation of a prominent left tibial tubercle on the Veteran's July 1970 separation examination; and ii. The Veteran's assertion that he injured his knee several time during service through several falls and by loading and moving the canon. 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. The term at least as likely as not does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. Any opinion expressed by the physician should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the physician should identify and specifically cite each reference material utilized. If the physician is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The physician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. The physician is also advised that noting that a condition did not manifest in service as the sole basis for forming a negative nexus opinion, without additional explanation, will not be adequate. 8. After completing the development in Section One above, and any additional development warranted by the record, obtain an advisory medical opinion from an appropriate medical expert, pursuant to 38 U.S.C. § 5109 and 38 C.F.R. § 3.328, regarding the nature and etiology of the Veteran's claimed cervical spine conditions. The AOJ must follow its established procedures for requesting such an advisory opinion. The entire claims file must be provided to, and reviewed by, the physician. If the physician determines it to be necessary, an examination should be scheduled and any indicated tests, studies, or evaluations should be conducted. The physician is asked to: 9. If an examination is conducted, obtain the Veteran's detailed lay history, including onset and progression of symptomatology. 10. For each diagnosed cervical spine condition, opine as to: i. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition had its onset during, or is otherwise related to, the Veteran's active duty service; ii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition was caused by a service-connected condition; and iii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition underwent an incremental increase (aggravated), regardless of permanence, by a service-connected condition. 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. The term at least as likely as not does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. Any opinion expressed by the physician should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the physician should identify and specifically cite each reference material utilized. If the physician is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The physician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. The physician is also advised that noting that a condition did not manifest in service as the sole basis for forming a negative nexus opinion, without additional explanation, will not be adequate. 11. After completing the development in Section One above, and any additional development warranted by the record, obtain an advisory medical opinion from an appropriate medical expert, pursuant to 38 U.S.C. § 5109 and 38 C.F.R. § 3.328, regarding the etiology of the Veteran's hypertension. The AOJ must follow its established procedures for requesting such an advisory opinion. The entire claims file must be provided to, and reviewed by, the physician. If the physician determines it to be necessary, an examination should be scheduled and any indicated tests, studies, or evaluations should be conducted. The physician is asked to: 12. If an examination is conducted, obtain the Veteran's detailed lay history, including onset and progression of symptomatology. 13. Opine as to: i. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition had its onset during, or is otherwise related to, the Veteran's active duty service, to include conceded herbicide exposure; ii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition was caused by a service-connected condition; and iii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition underwent an incremental increase (aggravated), regardless of permanence, by a service-connected condition. 14. In formulating the requested opinions, the physician is asked to consider and specifically address: i. The elevated blood pressure reading documented on the Veteran's separation examination; ii. The Veteran's assertion that his hypertension began in 1971; iii. The Veteran's lay history; and iv. The November 2018 National Academy of Sciences study, titled "Veterans and Agent Orange: Update 11," which moved hypertension from the "limited or suggestive" to "sufficient" category for association with herbicides. 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. The term at least as likely as not does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. Any opinion expressed by the physician should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the physician should identify and specifically cite each reference material utilized. If the physician is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The physician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. The physician is also advised that noting that a condition did not manifest in service as the sole basis for forming a negative nexus opinion, without additional explanation, will not be adequate. 15. After completing the development in Section One above, and any additional development warranted by the record, obtain an advisory medical opinion from an appropriate medical expert, pursuant to 38 U.S.C. § 5109 and 38 C.F.R. § 3.328, regarding the etiology of the Veteran's diverticulitis. The AOJ must follow its established procedures for requesting such an advisory opinion. The entire claims file must be provided to, and reviewed by, the physician. If the physician determines it to be necessary, an examination should be scheduled and any indicated tests, studies, or evaluations should be conducted. The physician is asked to: 16. If an examination is conducted, obtain the Veteran's detailed lay history, including onset and progression of symptomatology. 17. Opine as to: i. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition had its onset during, or is otherwise related to, the Veteran's active duty service, to include conceded herbicide exposure; ii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition was caused by a service-connected condition, to include medication or treatment therefor; and iii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition underwent an incremental increase (aggravated), regardless of permanence, by a service-connected condition, to include medication or treatment therefor. 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. The term at least as likely as not does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. Any opinion expressed by the physician should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the physician should identify and specifically cite each reference material utilized. If the physician is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The physician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. The physician is also advised that noting that a condition did not manifest in service as the sole basis for forming a negative nexus opinion, without additional explanation, will not be adequate. The physician is further advised that relying on the list of presumptive conditions under 38 C.F.R. § 3.309(e) to exclude the possibility of service connection on a direct basis would be considered inadequate. 18. After completing the development in Sections One and Five above, and any additional development warranted by the record, obtain an advisory medical opinion from an appropriate medical expert, pursuant to 38 U.S.C. § 5109 and 38 C.F.R. § 3.328, regarding the etiology of the Veteran's hemorrhoids. The AOJ must follow its established procedures for requesting such an advisory opinion. The entire claims file must be provided to, and reviewed by, the physician. If the physician determines it to be necessary, an examination should be scheduled and any indicated tests, studies, or evaluations should be conducted. The physician is asked to: 19. If an examination is conducted, obtain the Veteran's detailed lay history, to include onset and progression of symptomatology. 20. Opine as to: i. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition had its onset during, or is otherwise related to, the Veteran's active duty service; ii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition was caused by a service-connected condition, to include medication or treatment therefor; and iii. Whether it is at least as likely as not (i.e. a 50 percent or greater probability) that such condition underwent an incremental increase (aggravated), regardless of permanence, by a service-connected condition, to include medication or treatment therefor. 21. In formulating the requested opinions, the examiner is asked to consider and specifically address the Veteran's contention that his hemorrhoids are related to heaving lifting during service. 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. The term at least as likely as not does not mean within the realm of medical possibility. Rather, it means that the weight of the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion (e.g., etiology) as it is to find against the conclusion. Any opinion expressed by the physician should be accompanied by a complete rationale. If medical literature is relied upon in rendering a determination, the physician should identify and specifically cite each reference material utilized. If the physician is unable to offer an opinion without resort to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. The physician is advised that the Veteran is competent to report symptoms, treatment, and injuries, and that his reports must be taken into account in formulating the requested opinions. The physician is also advised that noting that a condition did not manifest in service as the sole basis for forming a negative nexus opinion, without additional explanation, will not be adequate. 22. 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 J. T. Martin III, 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.