Citation Nr: 21075872 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 17-39 889A DATE: December 21, 2021 ORDER Service connection for bruxism is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to service connection for compensation purposes for tooth enamel damage is denied. Service connection for a sinus disorder (including chronic sinusitis) is granted, subject to the laws and regulations governing the payment of monetary benefits. Service connection for rhinitis is granted, subject to the laws and regulations governing the payment of monetary benefits. Service connection for esophagitis is granted, subject to the laws and regulations governing the payment of monetary benefits. Service connection for a liver disorder, to include hepatomegaly and hepatic steatosis, is granted, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD) due to military sexual trauma (MST), to include as due to contaminated water at Camp Lejeune, is remanded. Service connection for hepatitis C, to include as due to contaminated water at Camp Lejeune, is remanded. Service connection for scleroderma, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for a bone disorder, to include arthritis, bone deterioration, and avulsion fractures, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for a cervical spine disability, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for a low back disability, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for a bilateral foot disability, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for costochondritis, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for chronic pain, to include myalgia and myositis, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for a gastrointestinal disorder, to include nausea and abdominal pain, to include as due to contaminated water at Camp Lejeune, is remanded. Service connection for hematuria, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for sleep apnea, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for migraines, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for a respiratory disorder to include chronic obstructive pulmonary disease (COPD), bronchitis, and cough with hemoptysis, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for hypertension, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for a seizure disorder, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for a skin disorder, to include rashes and eczema, to include as due to contaminated water at Camp Lejeune is remanded. Service connection for restless leg syndrome, bilateral, to include as due to contaminated water at Camp Lejeune is remanded. FINDINGS OF FACT 1. The Veteran served at Camp Lejeune for more than 30 days during active service. 2. Resolving reasonable doubt in her favor, the Veteran's bruxism began during active service. 3. Tooth enamel damage is not a disability for compensation purposes. 4. Resolving reasonable doubt in her favor, the Veteran's sinus disorder (including chronic sinusitis) began during active service. 5. Resolving reasonable doubt in her favor, the Veteran's rhinitis began during active service. 6. Resolving reasonable doubt in her favor, the Veteran's liver disorder (hepatomegaly and hepatic steatosis) began during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for bruxism are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for tooth enamel damage, for compensation purposes, have not been met. 38 U.S.C. §§ 1131, 1712, 5107; 38 C.F.R. §§ 3.303, 3.381, 4.150. 3. The criteria for service connection for a chronic sinus disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for rhinitis are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for esophagitis are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for liver disorder (hepatomegaly and hepatic steatosis) are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the U.S. Marine Corps from November 1981 to April 1983. This case comes to the Board of Veterans' Appeals (Board) on appeal from a decision of the Agency of Original Jurisdiction (AOJ) dated in October 2015. In March 2019, the Board previously remanded this case to the AOJ for additional development. The case was subsequently returned to the Board. With regard to the claim for service connection for an acquired psychiatric disorder, the evidence shows that the Veteran has been diagnosed with more than one psychiatric disorder, and her claim therefore encompasses all of these diagnoses. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that the scope of a mental health disability claim includes any mental disability that reasonably may be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The Board notes that the Veteran is unrepresented before VA, and she is advised that she may appoint a representative to assist with her appeal. Service Connection The Veteran contends that she has multiple physical and psychiatric symptoms and disabilities due to drinking contaminated water at Camp Lejeune for 90 days during service in the USMC in 1982. She stated that she lived in the barracks on the base, and was exposed to three times as much contaminated water as other military personnel because of the high temperatures while she worked in the bakery. She contends that all of the claimed conditions should be considered together, and that there was a chain of effects in which one health issue led to another, and another. See her November 2016 notice of disagreement and statement, and statements received in June 2014, October 2018, and July 2020. The Veteran's claimed disabilities due to contaminated water at Camp Lejeune are an acquired psychiatric disorder including depression and insomnia; a liver disorder including liver enlargement (hepatomegaly) and fatty liver disease (hepatic steatosis); a gastrointestinal disorder including esophagitis, nausea, and abdominal pain; sleep apnea; seizures; hypertension; hepatitis C; migraines; a skin disorder to include rashes; a bone disorder to include arthritis, osteoarthritis, bone deterioration, and avulsion fractures; a neck/cervical spine disability; a low back disability; a bilateral foot disability; chronic pain to include myalgia and myositis; restless legs syndrome; a respiratory disorder to include COPD, bronchitis, and cough with hemoptysis; a sinus disorder to include maxillary ethmoid sinus mucosal disease; scleroderma; costochondritis; hematuria; and teeth grinding (bruxism) with loss of tooth enamel. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. The three elements required to establish service connection are: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 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). Certain chronic diseases, including arthritis, bronchiectasis, cardiovascular-renal disease including hypertension, cirrhosis of the liver, epilepsies, systemic lupus erythematosus, organic diseases of the nervous system, osteomalacia, psychoses, scleroderma, tumors, malignant, or of the brain or spinal cord or peripheral nerves, and peptic ulcers will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted on a presumptive basis for certain diseases associated with exposure to contaminants (defined as the volatile organic compounds trichloroethylene (TCE), perchloroethylene (PCE or PERC), benzene, and vinyl chloride) in the on-base water supply located at Camp Lejeune, even though there is no record of such disease during service, if they manifest to a compensable degree at any time after service, in a veteran, former reservist, or a member of the National Guard, who had no less than 30 days (consecutive or nonconsecutive) of service at the United States Marine Corps Base Camp Lejeune and or Marine Corps Air Station New River in North Carolina, during the period beginning on August 1, 1953, and ending on December 31, 1987. 38 C.F.R. §§ 3.307 (a)(7), 3.309 (f). The following diseases shall be service-connected even though there is no record of such disease during service, subject to the rebuttable presumption provisions of 3.307 (d): kidney cancer, liver cancer, non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. 38 C.F.R. § 3.309 (f). The Veteran's service personnel records show that she was stationed at Camp Lejeune from February 2, 1982 to April 22, 1982, with a period of leave from January 22 to 31. During this time the Veteran completed the basic baker course. The Board finds that since the Veteran served at Camp Lejeune for more than 30 days during the relevant period, she is presumed to have been exposed to contaminated water during such service. However, her claimed conditions are not diseases for which presumptive service connection based on exposure to contaminated water at Camp Lejeune may be granted. 38 C.F.R. § 3.309 (f). The Veteran may also establish service connection for the claimed disabilities on the basis of direct causation. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). 1. Service connection for bruxism to include as due to contaminated water at Camp Lejeune The Veteran contends that she has teeth grinding (bruxism) with tooth enamel loss due to drinking contaminated water at Camp Lejeune for 90 days during service in the USMC in 1982. See her November 2016 notice of disagreement and statement, and statements received in June 2014, October 2018, and July 2020. Alternatively, she contends that she began grinding her teeth in service, which continued ever since, and that she was given a mouth guard in 1984. See November 2020 VA dental examination. During the pendency of this appeal, a Final Rule prohibiting bruxism as a stand-alone disability was promulgated in August 2017. See 82 Fed. Reg. 36080-36086 (Aug. 3, 2017). This Final Rule against bruxism as a stand-alone disability became effective on September 10, 2017. However, the United States Supreme Court has held that statutes generally may not be construed to have retroactive effect unless their language requires that result. See Landgraf v. USI Film Products, 511 U.S. 244 (1994). Although the discussion in Landgraf referred primarily to statutes, the presumption of non-retroactivity applies equally to regulations. See Regions Hosp. v. Shalala, 522 U.S. 448, 456 (1998). In this case, the appeal for service connection for bruxism was pending prior to the September 10, 2017 effective date of the regulation change, so the regulatory bar against bruxism does not apply to this Veteran's claim. The November 2020 VA dental examination and January 2021 medical opinion show the Veteran has current diagnoses of bruxism and temporomandibular disorder (TMD). The question before the Board is whether current bruxism is related to service. The Board concludes that the Veteran has a current disability that began during active service. 38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service treatment and dental records are silent for bruxism, but show that on one occasion she was diagnosed with situational stress disorder. See service treatment record dated in August 1982. The Board finds that the Veteran's reports that she began grinding her teeth in service and continued afterward are competent and credible. In a June 2020 VA medical opinion, the examiner opined that the Veteran's bruxism was not caused by or a result of her exposure to contaminated water at Camp Lejeune, but did not provide an opinion as to whether bruxism is otherwise related to service. The opinion was based on a review of the medical records of record, and the examiner stated that he could not identify objective evidence confirming the diagnosis of bruxism (teeth grinding). In a November 2020 VA dental examination and January 2021 VA medical opinion, the examiner, a dentist, diagnosed bruxism and opined that the claimed condition is at least likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that the clinical examination revealed generalized severe wear facets, she had been diagnosed with bruxism, and the Veteran reported that her stress began in service. The examiner stated that scientific research shows that there is a direct link between stress and the claimed condition of teeth grinding. The examiner stated that according to the Mayo Clinic, bruxism is defined as a condition in which one grinds, gnashes, or clenches the teeth, and can lead to jaw disorders, headaches, damaged teeth, and other problems. There are many factors that increase one's risk of bruxism, and stress is one of those factors. The examiner opined that the most likely etiology of the Veteran's bruxism is stress/anxiety. The January 2021 VA dental opinion is the most probative evidence of record addressing a causal link between the Veteran's current bruxism and her military service, because the examiner performed a physical examination and diagnosed bruxism, and the opinion is supported by an adequate rationale. The June 2020 VA medical opinion is less probative, because the examiner did not examine the Veteran or provide an opinion as to whether bruxism is related to service for any reason other than exposure to contaminated water at Camp Lejeune. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current bruxism arose in service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for bruxism is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service connection for tooth enamel damage to include as due to contaminated water at Camp Lejeune The Veteran contends that she has tooth enamel loss due to contaminated water at Camp Lejeune during service. Alternatively, she contends that she began grinding her teeth in service, which continued ever since, and that she has loss of tooth enamel as a result. Compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150, such as impairment of the mandible, loss of a portion of the ramus, and loss of a portion of the maxilla. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease will be considered service connected solely for the purpose of establishing eligibility for outpatient dental treatment as provided in 38 C.F.R. § 17.161. 38 C.F.R. § 3.381 (b). The Board notes that because the AOJ has not adjudicated the claim of service connection for tooth enamel damage for treatment purposes under 38 C.F.R. § 17.161, that issue is not in appellate status. After reviewing all the evidence, the Board finds that the weight of the evidence is against the claim. Damaged tooth enamel is not a compensable disability. 38 C.F.R. § 3.381 (b). Accordingly, as the Veteran has not presented a service connection claim for which compensation may be granted, the claim for service connection for tooth enamel damage for compensation purposes must be denied as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994). 3. Service connection for a sinus disorder, to include as due to contaminated water at Camp Lejeune 4. Service connection for rhinitis, to include as due to contaminated water at Camp Lejeune 5. Service connection for esophagitis, to include as due to contaminated water at Camp Lejeune 6. Service connection for a liver disorder, to include hepatomegaly and hepatic steatosis, to include as due to contaminated water at Camp Lejeune The Veteran contends that she has a sinus disorder, rhinitis, a respiratory disorder, esophagitis, and a liver disorder, to include hepatomegaly (enlarged liver), and hepatic steatosis (fatty liver) due to drinking contaminated water at Camp Lejeune during service. Considering the claims on the basis of direct service connection, the Board concludes that the Veteran has current disabilities that are related to service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Private treatment records and November 2020 VA examination reports show that the Veteran has current diagnoses of chronic sinusitis, chronic allergic rhinitis, esophagitis, hepatomegaly, and hepatic steatosis. See private medical records from WellSpan, Hershey Medical Center, and UPMC, and VA examinations and opinions dated in November 2020 and January 2021. Service treatment records are silent for the claimed conditions, but the Veteran is presumed to have been exposed to contaminated water during service at Camp Lejeune. Thus, the question becomes whether the current disabilities are related to service. On this question there are probative opinions in favor of and against the claim. Both the June 2020 VA examiner and the January 2021 VA examiner referenced the Agency for Toxic Substances and Disease Registry (ATSDR) of the U.S. Centers for Disease Control and Prevention (CDC) in their supporting rationales. The evidence against the claim includes the June 2020 opinions of a VA examiner who is a subject matter expert regarding contaminated water at Camp Lejeune. The examiner reviewed the claims file and medical records that were available at the time, and opined that the claimed conditions are not related to contaminated water at Camp Lejeune. The rationale was that after reviewing the "ATSDR Assessment of the Evidence for the Drinking Water Contaminants at Camp Lejeune and Specific Cancers and Other Diseases," published in 2017, and the general medical literature, there are no studies cited that document allergic rhinitis, chronic sinusitis, liver enlargement, or hepatic steatosis (nonalcoholic fatty liver disease (NAFLD)) as sequelae to exposure to contaminated water at Camp Lejeune. Since that time additional pertinent evidence has been added to the claims file, including private medical records, reports of VA examinations conducted in November 2020, and VA medical opinions dated in January 2021. The evidence in favor of the claim includes the January 2021 opinions by the VA examiner who performed VA examinations of the Veteran in November 2020. The examiner opined that the sinus disorder (maxillary ethmoid sinus condition and sinus mucosal disease), liver enlargement (hepatomegaly), hepatic steatosis, were at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. The rationale was that after reviewing the claims, the medical records, and the website of the ATSDR regarding Camp Lejeune (atsdr.cdc.gov/sites/lejeune/background.html), the examiner concluded that the tainted water which had Trichloroethylene, tetrachloroethylene, and vinyl chloride and other contaminants is likely to have caused the Veteran's sinus disorder, rhinitis, esophagitis, liver enlargement, and hepatic steatosis. The examiner noted that there are many health effects from such exposure including chonal atresia, eye defects, breast cancer, cervical cancer, esophageal cancer, lung cancer, Hodgkins disease, ovarian cancer, prostate cancer, rectal cancer, impaired immune system, neurological effects, neurobehavior performance deficits, severe, generalized hypersensitivity skin disorder, aplastic anemia, myelodysplastic syndrome, miscarriages, and liver problems. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current chronic sinusitis, rhinitis, esophagitis, and a liver disorder (hepatomegaly and hepatic steatosis) are related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for chronic sinusitis, rhinitis, esophagitis, and a liver disorder (hepatomegaly and hepatic steatosis) is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Service connection for an acquired psychiatric disorder to include PTSD and depression is remanded. Unfortunately, there has not been substantial compliance with the Board's previous remand directives regarding the issue of service connection for an acquired psychiatric disorder. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Although a VA medical opinion was obtained in June 2020, and a VA psychological examination and medical opinion were obtained in February 2021, the Board finds that these opinions are inadequate as it does not appear that the examiners reviewed pertinent service treatment records showing that the Veteran had at least two suicide attempts in service, and was diagnosed with situational stress disorder in late August 1982. See service treatment records dated on August 28, 1982 and September 2, 1982, and Medical Board dated March 24, 1983. The March 1983 Medical Board found that the Veteran had a pre-existing personality disorder of such severity that it rendered her unsuitable for military service. She was diagnosed with character disorder, passive-aggressive type, severe, existing prior to entry, polydrug abuse, and chronic alcoholism in remission. A December 2019 private medical record from N.R. Garverick, CRNP reflects that the Veteran reported a history of PTSD. The diagnosis was dysthymia. At the February 2021 VA psychological examination, the Veteran reported that she was raped during service, while stationed at school at Camp Johnson after boot camp, within the first six months of service, and that she worked with the perpetrator in the bakery. The examiner diagnosed nightmare disorder, REM sleep behavior disorder, and unspecified depressive disorder with anxious distress, but did not diagnose PTSD. In light of the Veteran's contention that she suffered MST in service and incurred a psychiatric disorder in service, and her report of PTSD diagnosis, the Board has broadened her claim of service connection for a psychiatric disorder to include PTSD due to MST. More information is needed to allow the Board to make a fully-informed decision. It is unclear whether the Veteran has a current diagnosis of PTSD under the DSM-5. The Board also notes that the United States Court of Appeals for the Federal Circuit and the United States Court of Appeals for Veterans Claims have both held that, for a PTSD claim stemming from an in-service personal assault, under 38 C.F.R. § 3.304 (f)(5), a VA medical opinion may be secured to determine whether the occurrence of an in-service assault stressor is corroborated. Menegassi v. Shinseki, 638 F.3d 1379, 1383 (Fed. Cir. 2011); Bradford v. Nicholson, 20 Vet. App. 200, 207 (2006); Patton v. West, 12 Vet. App. 272, 280 (1999). Therefore, on remand the examiner should provide an opinion as to whether the Veteran's assault stressor is verified. In this regard, the Board notes that service personnel records show that from February 1982 to April 1982, the Veteran was a student assigned to FSS Company, at Marine Corps Service Support Schools (MCSSS), Marine Corps Base, Camp Lejeune, during which time she completed the basic baker course. (Camp Johnson is a satellite camp of MCB Camp Lejeune.) The Veteran was treated for a suicide attempt in August 1982 and diagnosed with alcohol abuse, suicide gestures, situational stress disorder, and habitual excessive drinking. On remand, the AOJ should attempt to obtain any outstanding private medical records of treatment for a psychiatric disorder. 2. Service connection for hepatitis C is remanded. With regard to the claim of service connection for hepatitis C, the Board finds that the medical evidence is contradictory as to whether the Veteran has had a current diagnosis of hepatitis C during the pendency of the appeal, and a supplemental medical opinion is required. Initially, the Board notes that in June 2014, the Veteran claimed service connection for "acute hepatitis C," and in the rating decision on appeal, the AOJ denied service connection for acute hepatitis C. The issue of chronic hepatitis C must also be considered. Private medical records from Gettysburg Hospital dated in December 2008 (several years prior to the claim on appeal) reflect that laboratory results were positive for the hepatitis C virus (HCV). However, laboratory studies performed during the pendency of the appeal at the November 2020 VA examination indicated that the pattern of results shown (undetectable HCV RNA combined with reactive HCV antibody) could be consistent with a resolved past infection if the clinical history is compatible with previous HCV exposure, but if no previous exposure is suspected, the reactive HCV antibody could be a biological false positive result. Although the January 2021 VA examiner opined that the Veteran has acute hepatitis C that is at least as likely as not related to contaminated water in Camp Lejeune, the June 2020 VA examiner opined that the Veteran's medical records showed a diagnosis of chronic Hepatitis C infection, but it was not in the acute phase, and not caused by contaminated water at Camp Lejeune. The June 2020 VA examiner opined that exposure to contaminated water at Camp Lejeune did not cause viral hepatitis. The examiner stated that the hepatitis C virus (HCV) can cause both acute and chronic hepatitis. The acute process is self-limited, rarely causes hepatic failure, and usually leads to chronic infection. Chronic HCV infection often follows a progressive course over many years. This claim is remanded for a supplemental medical opinion to reconcile the medical opinions of record and to determine whether the Veteran has had current hepatitis C during the pendency of the appeal that is related to service. Issues Remanded for Private Medical Records 3. Service connection for scleroderma is remanded. 4. Service connection for a bone disorder, to include arthritis, bone deterioration, and avulsion fractures is remanded. 5. Service connection for a cervical spine disability is remanded. 6. Service connection for a low back disability is remanded. 7. Service connection for a bilateral foot disability is remanded. 8. Service connection for costochondritis is remanded. 9. Service connection for chronic pain, to include myalgia and myositis, is remanded. 10. Service connection for a gastrointestinal disorder, to include nausea and abdominal pain is remanded. 11. Service connection for sleep apnea is remanded. 12. Service connection for a respiratory disorder to include COPD, bronchitis, and cough with hemoptysis is remanded. 13. Service connection for migraines is remanded. 14. Service connection for a seizure disorder is remanded. 15. Service connection for a skin disorder, to include rashes and eczema, is remanded. 16. Service connection for restless leg syndrome is remanded. 17. Service connection for hematuria is remanded. 18. Service connection for hypertension is remanded. The Board finds that these issues must be remanded to obtain outstanding private medical records. In a November 2020 statement, the Veteran identified relevant outstanding private treatment records from UPMC Pinnacle, WellSpan Health, PennState Health, and Associated Otolaryngologists of PA. A remand is required to allow VA to obtain authorization and request these records. Moreover, in light of the present award of service connection for bruxism, sinusitis, rhinitis, esophagitis, and a liver disorder, a supplemental medical opinion should be obtained to determine whether any of the remaining conditions are secondary to a service-connected disability. The examiner is also asked to reconcile the conflicting VA medical opinions of record. Previously, in April 2015, the Veteran identified treatment from other private medical providers. At that time, she submitted a VA Form 21-4142a (General Release for Medical Provider Information to VA), but did not submit a signed VA Form 21-4142 (Authorization to Disclose Information to the VA). In the April 2015 VA Form 21-4142a, she reported receiving private medical treatment from N. Garverick at Herrs Ridge Family Practice from 1995 to 2015, from Dr. Diaz and Dr. Spears at Hanover Hospital for 20 years to the present, and from Drs. Mosser, Imadjemu, Diehl, and Lin at Patient Care Team for 20 years. In November 2016, the Veteran submitted a VA Form 21-4142 with her notice of disagreement and contended that VA had never attempted to obtain the identified private medical records. In an April 2017 deferred rating decision, the AOJ determined that additional development was needed because the Veteran submitted a VA Form 21-4142a in April 2015, but did not include a VA Form 21-4142. By a letter to the Veteran dated in May 2017, the AOJ asked her to complete and return both a VA Form 21-4142 and a VA Form 21-4142a, to enable VA to obtain treatment records on her behalf. Since then, although the Veteran has submitted some private medical records, and had identified additional treatment providers (see August 2017 substantive appeal and November 2020 statement), she has not completed a new VA Form 21-4142. In the August 2017 substantive appeal, the Veteran reported treatment by Dr. Spears at Hanover Hospital and York Hospital, Dr. Parris, DPM at Hillside Medical Center, Dr. Kratz and N. Garverick at Herrs Ridge Family Practice, Dr. Bischoff at Hanover Orthopedic, Dr. Lin (neurology), Dr. Diehl (rheumatology), Dr. Imadjemu (pulmonology), Dr. Schlegel (neurosurgery) and J. Capers, PA-C at Hershey Medical Center, Dr. French (otolaryngology), Dr. Diaz (gastroenterology). She also stated that she had also been treated by other doctors in the past 30 years. On remand, the AOJ should attempt to obtain the identified medical records. The Veteran is advised that she must complete all required VA authorization forms in order for VA to assist her in obtaining such records. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a new VA Form 21-4142 for UPMC Pinnacle, WellSpan Health, PennState Health, Associated Otolaryngologists of PA, Herrs Ridge Family Practice, Dr. Diaz, Dr. Spears, Hanover Hospital, Patient Care Team, Dr. Parris, DPM at Hillside Medical Center, Dr. Bischoff at Hanover Orthopedic, Dr. Lin (neurology), Dr. Diehl (rheumatology), Dr. Imadjemu (pulmonology), Dr. Schlegel (neurosurgery) and J. Capers, PA-C at Hershey Medical Center, and Dr. French, and any provider who treated her for a psychiatric disorder. See April 2015 VA Form 21-4142a, August 2017 substantive appeal, and November 2020 statement. Make two requests for the authorized records from these medical providers, unless it is clear after the first request that a second request would be futile. 2. Send the Veteran notice required for PTSD claims based on personal assaults, and allow time for a response. Then, attempt to corroborate the Veteran's in-service stressor based on personal assault, including MST during the period from February 1982 to April 1982. If more details are needed, contact the Veteran to request the information. 3. After the Veteran's reported stressors have been developed, obtain an addendum opinion from the examiner who performed the February 2021 VA examination (or, if unavailable, an appropriate clinician) regarding whether (a) the Veteran has a diagnosis of PTSD, and (b) whether any current psychiatric disorder is at least as likely as not related to an in-service injury, event, or disease, to include claimed MST in early 1982 and the August 1982 diagnosis of situational stress disorder. Service treatment records document suicide attempts in August 1982 and February 1983; the latter was during inpatient treatment. An examination need only be performed if deemed necessary by the examiner. In light of the fact that the March 1983 Medical Board diagnosed character disorder, passive-aggressive type, severe, existing prior to entry, please respond to the following: (c) Did a psychiatric disorder clearly and unmistakably (undebatable) preexist the Veteran's service? (d) If the examiner finds that a psychiatric disorder did clearly and unmistakably preexist service, was it clearly and unmistakably NOT aggravated by service? (e) If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. (f) If the Veteran is diagnosed with PTSD, the examiner must opine whether the PTSD was at least as likely as not superimposed on a personality disorder during active service and resulted in additional disability. (g) The examiner must opine whether the evidence of record, including the Veteran's lay statements, and the Veteran's service records, corroborate the claim that a personal assault occurred in service (38 C.F.R. § 3.304(f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran's active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran has had a diagnosis of hepatitis C during the pendency of the appeal that is at least as likely as not related to service. The examiner is asked to review the claims file and reconcile the June 2020 and January 2021 VA medical opinions regarding hepatitis C, with consideration of the November 2020 VA laboratory findings (received on January 21, 2021), and the December 2008 private laboratory findings (received on June 2, 2014). 5. Obtain an addendum opinion from an appropriate clinician based on a review of the claims file and any additional records obtained on remand regarding whether each of the Veteran's claimed disabilities of scleroderma; bone disorder, to include arthritis, bone deterioration, and avulsion fractures; cervical spine disability; low back disability; bilateral foot disability; costochondritis; chronic pain, to include myalgia and myositis; gastrointestinal disorder, to include nausea and abdominal pain; hematuria; sleep apnea; migraines; respiratory disorder to include COPD, bronchitis, and cough with hemoptysis; hypertension; seizure disorder; skin disorder; and restless legs syndrome is (a) at least as likely as not related to service, (b) proximately due to service-connected disability, or (c) aggravated i.e., worsened beyond its natural progression by service-connected disability. (d) Is it at least as likely as not that arthritis or hypertension (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Provide a rationale to support the opinions. An examination need only be performed if deemed necessary by the examiner. The examiner should also respond to the following, and attempt to reconcile the VA medical opinions of record: (e) With regard to each claimed disability: is it at least as likely as not related to contaminants in the water during service at Camp Lejeune? The examiner is advised that a negative opinion cannot be based solely on the fact that the claimed disability is not on the list of diseases that are presumptively associated with exposure to contaminants in the water supply at Camp Lejeune If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinions. In providing the requested opinions, consider the Veteran's description of her in-service injury and symptoms as well as post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of her current disability, this should be noted. Stated another way, do the Veteran's reports about her symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? J.N. Moats Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. L. Wasser, 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.