Citation Nr: 21076818 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 16-58 526 DATE: December 27, 2021 ORDER Secondary service connection for a sleep disorder, to include obstructive sleep apnea and non-obstructive alveolar hypoventilation, including with obesity as an intermediate step, is granted. REMANDED An increased rating in excess of 10 percent for right knee degenerative joint disease (DJD) is remanded. An increased rating in excess of 20 percent for cervical spine degenerative disc disease (DDD) is remanded. An increased rating in excess of 20 percent for thoracolumbar degenerative disc disease (DDD) is remanded. Entitlement to aid and attendance and/or other special monthly compensation is remanded. FINDING OF FACT Giving the Veteran the benefit of the doubt, the Veteran's sleep disorder, to include obstructive sleep apnea and non-obstructive alveolar hypoventilation, is due to service-connected disability, including with obesity as an intermediate step. CONCLUSION OF LAW The criteria for secondary service connection for a sleep disorder, to include obstructive sleep apnea and non-obstructive alveolar hypoventilation, including with obesity as an intermediate step, have been met. 38 U.S.C. § 5107; 38 C.F.R. § 3.310; VAOPGCPREC 1-2017 (January 6, 2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1965 to July 1967 and from August 1981 to December 1992. This matter originally came before the Board of Veterans' Appeals (Board) from February 2014 and May 2014 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The Veteran testified at a March 2020 Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. This matter was previously remanded by the Board for further development in June 2020. This matter is again before the Board and has been advanced on the docket pursuant to 38 C.F.R. § 20.902(c). Service connection for a sleep disorder, to include obstructive sleep apnea and non-obstructive alveolar hypoventilation, is granted. The Veteran believes that service connection for a sleep disorder, to include obstructive sleep apnea and non-obstructive alveolar hypoventilation, is warranted. See November 2021 Appellate Brief. Obstructive sleep apnea Obesity cannot be the underlying basis for a grant of service connection; however, obesity may be an "intermediate step" between a service-connected disability and a current disability, which may be connected on a secondary basis. This requires (1) a service-connected disability to have caused the Veteran to become obese, (2) the obesity to have been a substantial factor in causing the current disability, and (3) the current disability to have not occurred but for the obesity. See 38 C.F.R. § 3.310; VAOPGCPREC 1-2017 (January 6, 2017). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Veteran will receive the benefit of the doubt. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The medical evidence of record shows that the Veteran has a current diagnosis of obstructive sleep apnea. The Veteran's claims file shows that the Veteran is already service connected for post-polio syndrome, a lumbar spine disability, and a right knee disability. See September 2020 C&P Exam; September 2021 Rating Decision Codesheet. A medical examination from 2021 found that the Veteran's obesity was an intermediate step in the development of obstructive sleep apnea; that the Veteran's obesity was caused by the Veteran's service-connected post-polio syndrome, thoracolumbar spine disability, and right knee disability; and that the Veteran's obstructive sleep apnea likely would not have occurred but for the obesity. See September 2021 C&P Exam. A previous medical examination in 2020 found that the Veteran's obstructive sleep apnea was caused by obesity. See September 2020 C&P Exam. As such, medical records show that the Veteran's service-connected disabilities caused the Veteran to become obese, the obesity was at least a substantial factor in causing the Veteran's obstructive sleep apnea, and the obstructive sleep apnea would not have occurred but for the obesity. Therefore, giving the Veteran the benefit of the doubt, secondary service connection for obstructive sleep apnea, with obesity as an intermediate step, is granted. Non-obstructive alveolar hypoventilation Secondary service connection is warranted if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Veteran will receive the benefit of the doubt. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The medical evidence of record shows that the Veteran has a current diagnosis of non-obstructive alveolar hypoventilation. See September 2020 C&P Exam. Therefore, the first element of secondary service connection has been met. The Veteran is already service connected for post-polio syndrome. See September 2021 Rating Decision Codesheet. Therefore, the second element of secondary service connection has been met. The final element needed for secondary service connection is a link between the Veteran's non-obstructive alveolar hypoventilation and the Veteran's service-connected post-polio syndrome. A medical examination from 2021 found that the Veteran's non-obstructive alveolar hypoventilation was directly caused by the Veteran's post-polio syndrome, because the post-polio syndrome caused thoracic muscle weakness, which in turn affected respiration function. See September 2021 C&P Exam. Therefore, the Board gives the Veteran the benefit of the doubt and finds that the third and final element of secondary service connection has been met. Therefore, secondary service connection for non-obstructive alveolar hypoventilation is granted. REASONS FOR REMAND 1. An increased rating in excess of 10 percent for right knee DJD, an increased rating in excess of 20 percent for cervical spine DDD, and an increased rating in excess of 20 percent for thoracolumbar DDD are remanded. The Veteran believes that increased ratings for right knee DJD, cervical spine DDD, and thoracolumbar spine DDD are warranted. See November 2021 Appellate Brief. The Board previously found the March 2016 VA examinations for these disabilities inadequate and remanded these issues for new VA examinations. See June 2020 BVA Decision. The examinations took place in September 2020. See September 2020 C&P Exam. The thoracolumbar spine examination found, among other things, that the Veteran managed his back pain with oral analgesics, forward flexion to 45 degrees, and pain during forward flexion. The cervical spine examination found, among other things, initial forward flexion to 30 degrees, pain during forward flexion, and forward flexion with repeated use over time and during flare ups to 20 degrees. The right knee examination found, among other things, initial flexion to 110 degrees and flexion with repeated use over time and during flare ups to 90 degrees. In November 2020, an addendum opinion was provided for the thoracolumbar spine, which noted that flexion could not be tested to the full range of motion while standing due to safety concerns of a potential fall. See November 2020 C&P Exam. The Board finds that a remand is needed for new examinations. Specifically, none of these examinations/opinions appear to have considered the ameliorative effects of medication when evaluating the current nature and severity of the Veteran's disabilities. See Jones v. Shinseki, 26 Vet. App. 56 (2012) (when a Diagnostic Code is silent as to the effects of medication, VA may not deny entitlement to a higher disability rating based on the relief provided by medication). Additionally, the right knee examination did not consider the Veteran's report that the right knee would swell, give out, snap, click, and did not have cartilage; as well as medical records showing right knee pain being controlled with medication and that the right knee would swell at times. See November 2021 Appellate Brief; Hearing Transcript; February 2014 CAPRI; July 2013 Medical Treatment Record. Finally, none of the examinations provided non-weight bearing range of motion measurements and the right knee examination also did not provide passive range of motion measurements as required by the June 2020 Board remand. See June 2020 BVA Decision; Stegall v. West, 11 Vet. App. 268 (1998). Therefore, a remand is needed for new VA examinations that will consider the severity of these disabilities throughout the entire appeal period. 2. Entitlement to aid and attendance and/or other special monthly compensation is remanded. The Veteran believes that aid and attendance and/or other special monthly compensation is warranted. See November 2021 Appellate Brief. In a June 2020 Board decision, the Board remanded the special monthly compensation issue for a VA examination. The examination was to assess the nature and severity of the Veteran's service-connected disabilities and the impact that they had on his activities of daily living. The examiner was to consider and discuss all pertinent medical and lay evidence. See June 2020 BVA Decision. The examination took place in September 2020. See September 2020 C&P Exam. The examination mentioned the Veteran's service-connected cervical spine, thoracolumbar spine, and right knee, but did not discuss the Veteran's other service-connected disabilities. The examination also noted that the Veteran needed assistance with dressing, undressing, bathing, and grooming due to debility owing to age, some service-connected disabilities, and body habitus. An addendum opinion took place in November 2020. See November 2020 C&P Exam. The addendum opinion noted that the previous examination did not consider all of the Veteran's service-connected disabilities. The addendum opinion found that the Veteran's need for assistance for dressing, bathing, cooking, and chores was more due to age and body habitus, although it may have been somewhat affected by the thoracolumbar spine disability. The Board finds that a remand is needed for a new examination because there was not substantial compliance with the June 2020 Board remand instructions and because not all of the relevant evidence was considered. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, the nature and severity of all of the Veteran's service-connected disabilities and the impact that they had on the Veteran's activities of daily living were not provided, as required by the June 2020 Board remand, and only information from three of the Veteran's service-connected disabilities were considered, meaning that relevant evidence concerning the other service-connected disabilities was not considered. Additionally, the examination and opinion did not address whether aid and attendance was needed during the years prior to when they were conducted. As such, there is currently insufficient medical evidence of record to make a proper determination on the issue throughout the entire appeal period. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Therefore, a remand is needed for a new VA examination that will consider the need for aid and attendance based on service-connected disability throughout the entire appeal period. The matter is REMANDED for the following action: 1. Update VA and private treatment records. VA treatment records appear current up to January 2021. 2. Schedule one or more appropriate VA examinations to determine the nature and severity of the service-connected thoracolumbar spine, cervical spine, and right knee disabilities throughout the entire appeal period (i.e., since November 2013). This should include, but is not limited to, any muscle injuries and any neurological impairment. The claims file and a copy of this Remand should be made available to and should be reviewed by the examiner. Any studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner should report all signs and symptoms necessary for evaluating the Veteran's service-connected thoracolumbar spine, cervical spine, and right knee disabilities throughout the entire appeal period (i.e., since November 2013). This should include, but is not limited to, any muscle injuries and any neurological impairments. The severity of any muscle injuries (i.e., slight, moderate, moderately severe, or severe) and the severity of any neurological impairments (i.e., mild, moderate, severe incomplete paralysis, or complete paralysis of the affected nerves) should be assessed. Identify the specific muscle groups associated with any muscle injuries and identify the specific nerves associated with any neurological impairments. This should also include all symptoms and related impairment that would have been present without the relief provided by medications to treat the disabilities. The examiner should provide range of motion measurements in degrees. In so doing, the examiner should test the Veteran's range of motion in active motion, passive motion, weight-bearing, and in non-weight-bearing. Such range of motion results should be recorded in the report. If there is evidence of pain on motion, the examiner should indicate the degree of range of motion at which such pain begins. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, the examiner should clearly explain why in the report. The examiner must comment on the functional limitations caused by repetitive use over time and flare-ups due to the Veteran's connected spinal compression fractures. The examiner must indicate whether, and to what extent, the Veteran's range of motion is additionally limited after repetitive use over time and during flare-ups in terms of degrees, if possible. If it is not possible, the examiner should explain why, making clear that all procurable and assembled data (i.e., the information regarding frequency, duration, characteristics, severity, and/or functional loss related to repetitive use over time and flare-ups elicited from the Veteran) was considered, and that the medical community at large could not provide such an opinion without resorting to speculation. If it is not possible due to a deficiency in the record or a lack of personal medical knowledge, the examiner should state so. Any additional impairment on use or in connection with repetitive use over time and flare-ups should be described in terms of the degree of additional range of motion loss. If the Veteran states that the limitation on range of motion is variable, provide the range of variableness in terms of degrees. The examiner should specifically describe the severity, frequency, and duration of impairment after repetitive use over time and during flare-ups; name the precipitating and alleviating factors; and estimate, per the Veteran, to what extent, if any, such repetitive use over time and flare-ups affect functional impairment. This testing should be done regardless of whether the Veteran is tested after repetitive use over time or during a flare-up or not. The examiner should discuss whether, at any point during the appeal period (i.e., since November 2013), the Veteran has had the functional equivalent of ankylosis. If so, the examiner should discuss whether the ankylosis was favorable or unfavorable and provide the time periods in which it existed. The examiner should also provide estimates of what the Veteran's range of motion measurements, symptoms, and related impairment would have been/would be throughout the appeal period (i.e., since November 2013) with and without the ameliorative effects of medication used to treat the disabilities. In addition to the other relevant evidence of record, the examiner is asked to consider the following information with a caution that this list is not a substitute for a review of the record: Thoracolumbar spine (1) A medical record from 2020 showing lumbar spine forward flexion to 45 degrees with pain at 45 degrees. Flexion was not tested to the full range of motion while standing due to safety concerns. Loss of flexion would have impaired movements like bending at the waist. Further information is provided. See November 2020 C&P Exam. (2) Medical records from 2020 showing lumbosacral spondylosis and lumbar intervertebral disc degeneration. See September 2020 CAPRI. (3) A medical record from 2020 showing low back pain managed with oral analgesics. Sometimes, the pain went to both legs. The Veteran reported some weakness and numbness in the legs. There were weekly low back flare-ups which lasted from a brief moment to 30 minutes. Reflexes were a 1+. Further information is provided. See September 2020 C&P Exam. (4) Medical records from 2014 and 2015 showing lumbago and Tylenol #3, Tylenol #4, and Soma for the lumbar spine. See June 2020 CAPRI. (5) Medical records from 2012 showing chronic back pain being controlled on usual medications. Medical records from 2017 showed Acetaminophen, Codeine, and Carisoprodol for the lumbar spine. Medical records from 2018 showed lumbar spine tenderness on palpation and lumbar paravertebral spasm. See March 2020 Medical Treatment Record. (6) Medical records from 2000 showing thoracic or lumbosacral neuritis or radiculitis. See March 2020 CAPRI. (7) The Veteran's 2020 report that the 2016 VA examination was inadequate, and that real range of motion testing was not done. The Veteran was not asked to bend over and could not have bent over. See Hearing Transcript. (8) A medical record from 2016 showing treatment with Tylenol #4 and Soma. The Veteran reported flare-ups, which caused a 95% reduction in range of motion. The flare-ups occurred three to four times in the past year and lasted about three to four days. Initial forward flexion went to 60 degrees with pain. The Veteran was unable to fully bend over. Reflexes were a 1+ for the knee and ankle. Further information is provided. See March 2016 C&P Exam. (9) Medical records from 2013, 2014, and 2015 showing that low back pain was controlled with Tylenol #4 and Soma. The Veteran reported daily leg pain in muscles along the lateral aspect of the lower extremities with occasional numbness. Muscle strength for knee extension was a 4/5. See March 2016 CAPRI; February 2014 CAPRI. (10) All other relevant lay and medical evidence. Cervical spine (1) A medical record from 2020 showing cervical spine forward flexion to 30 degrees with pain at 30 degrees. Further information is provided. See November 2020 C&P Exam. (2) A medical record from 2020 showing the Veteran's report of random flare-ups lasting for 30 minutes. Initial forward flexion went to 30 degrees. Forward flexion with repetitive use over time and during flare-ups went to 20 degrees. Further information is provided. See September 2020 C&P Exam. (3) Medical records from 2020 showing cervical intervertebral disc displacement with myelopathy and a cervical sprain/strain. See March 2020 Medical Treatment Record. (4) The Veteran's 2020 report that the 2016 VA examination was inadequate, and that real range of motion testing was not done. See March 2020 Hearing Transcript. (5) Medical records showing cervicalgia. See March 2016 CAPRI. (6) A medical record from 2016 showing treatment with Tylenol #4 and Soma. The Veteran reported flare-ups in the past year that lasted about one day or so each time and reduced range of motion by 50%. Initial forward flexion went to 35 degrees. Reflexes were a zero for the triceps and brachioradialis. Further information is provided. See March 2016 C&P Exam. (7) Medical records from 2012 showing that cervical spine pain was controlled with Tylenol #3. See February 2014 CAPRI. (8) All other relevant lay and medical evidence. Right knee (1) A medical record from 2020 showing the Veteran's report of occasional buckling since 2016. The Veteran reported right knee swelling and flare-ups of pain when overactive on his leg. Ambulation would be impaired, and the flare-ups would last for several hours. Range of motion with repeated use over time and during flare-ups went from zero to 90 degrees and vice versa. Further information is provided. See September 2020 C&P Exam. (2) Medical records from 2018 showing small knee joint effusion and knee joint line tenderness. See March 2020 Medical Treatment Record. (3) The Veteran's 2020 report of the right knee snapping and giving out. When he walked, it would click. Sometimes, the knee just quit, and the Veteran would go down. The knee buckled sometimes and had become weak. The cartilage was gone. The Veteran also reported that the 2016 VA examination was inadequate, and that real range of motion testing was not done. Further information is provided. See Hearing Transcript. (4) A medical record from 2016 showing that the right knee was treated with Tylenol and Soma. The Veteran reported flare-ups six to seven times in the past 12 months which lasted about a day or two at a time. There was a 75% reduction in range of motion during flare-ups. Initial range of motion went from zero to 100 and vice versa. Further information is provided. See March 2016 C&P Exam. (5) Medical records from 2012 showing right knee crepitus. Right knee pain was controlled with Tylenol #3. See February 2014 CAPRI. (6) All other relevant lay and medical evidence. A complete and clear rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions. The Veteran and others are competent to attest to factual matters of which they have first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran and/or others, the examiner should provide a fully reasoned explanation. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community or the limits of the examiner's medical knowledge. 3. Schedule one or more appropriate VA examinations to determine the need for aid and attendance and/or other special monthly compensation due to the Veteran's service-connected disabilities. Following a review of the claims file and a copy of this Remand, the reviewing examiner is requested to furnish an opinion with respect to the following: (A) At any point during the appeal period (i.e., since February 2013), has the Veteran been unable to dress or undress or has the Veteran been unable to keep ordinarily clean and presentable? (B) At any point during the appeal period, has the Veteran required frequent adjustment of any special prosthetic or orthopedic appliances, which by reason of service-connected disabilities, could not be done without aid? (C) At any point during the appeal period, has the Veteran been unable to feed himself through loss of coordination of upper extremities or through extreme weakness, or has the Veteran been unable to attend to the wants of nature? (D) At any point during the appeal period, has the Veteran had incapacity, physical or mental, that required care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment? (E) At any point during the appeal period, has the Veteran had any disability or disabilities requiring him to remain in bed? If the answer is yes to any of the above, the examiner is requested to furnish an opinion with respect to the following: (F) For each service-connected disability, is it at least as likely as not (a 50 percent or greater probability) that the service-connected disability alone caused any of the above? If yes, which of the above? The examiner should also state which combinations of service-connected disabilities at least as likely as not (a 50 percent or greater probability) caused any of the above and list which of the above apply. The examiner should also describe what the effective remaining function of each lower extremity and each foot (including balance, propulsion, etc.) and each upper extremity and each hand (including grasping, manipulation, etc.) was during the appeal period based upon the Veteran's service-connected disabilities and explain which service-connected disabilities are responsible for what. Based on these findings, for each lower extremity, each foot, each upper extremity, and each hand, is it at least as likely as not (a 50 percent or greater probability) that no effective function remained/remains other than that which would be equally well served by an amputation stump at the site of election below the knee or elbow with use of a suitable prosthetic appliance. If applicable, provide an opinion as to the periods of time during the appeal period (i.e., since February 2013) that each was ascertainable. For each lower extremity and each upper extremity, the examiner should state whether there are factors preventing natural knee action with prostheses in place, or if there are factors preventing natural elbow action with prostheses in place. In addition to the other relevant evidence of record, the examiner is asked to consider the following information with a caution that this list is not a substitute for a review of the record: (1) The Veteran's 2021 report of the service-connected right knee bucking, swelling, giving out, and causing falls. See November 2021 Appellate Brief. (2) A medical record from 2021 showing that the Veteran's service-connected post-polio syndrome, thoracolumbar spine, and right knee disabilities caused his obesity. Fatigue, arm pain, leg pain, and diffuse muscle weakness (including in the lower extremities) was related to post-polio syndrome. The service-connected thoracolumbar spine and right knee disabilities also contributed to significant limitations in leg function. See September 2021 C&P Exam. (3) A medical record from 2021 showing that the Veteran was only able to walk a few steps independently and needed a motorized wheelchair for all other mobility. Service-connected post-polio syndrome and service-connected musculoskeletal disabilities played a role in arm and leg pain. Further information is provided. See August 2021 C&P Exam. (4) A medical record from 2021 showing pain in the lower extremities with occasional numbness. The Veteran could not walk more than a short distance. There was pain throughout the arms and legs and generalized fatigue. Service-connected post-polio syndrome resulted in weakness and diffuse pain that appeared to be the primary limiting factor in lack of mobility endurance. The service-connected right knee and spine disabilities played roles as well. The constant use of a wheelchair was due to post-polio syndrome. Post-polio syndrome resulted in severely limited mobility, strength, and lifting ability. Further information is provided. Id. (5) Medical records from 2020 showing that the Veteran had a caregiver and needed help with bathing, mobility, skin care, etc. See January 2021 CAPRI. (6) A medical record from 2020 showing that the service-connected thoracolumbar disability impaired movements like bending at the waist. The Veteran needed help with dressing, bathing, cooking, and chores. See November 2020 C&P Exam. (7) A medical record from 2020 showing a history of falls and that service-connected post-polio syndrome was involved. The Veteran reported right knee buckling from limb weakness. Further information is provided. See September 2020 C&P Exam. (8) A medical record from 2020 showing that thoracolumbar spine flexion testing was not fully done due to safety concerns of a potential fall. The service-connected cervical spine disability resulted in impaired head rotation. Constant imbalance affected the Veteran's ability to ambulate. He could only walk without help in the home. Propulsion was not normal, was slow, and was cautious. Id. (9) Medical records from 2018 showing a disordered thought process and that the Veteran was unable to prepare meals, grocery shop, manage money, do housework, manage medications, or use the phone independently. See March 2020 Medical Treatment Record. (10) Medical records from 2017 showing that the Veteran continued to need help with transferring to his wheelchair, bathing, dressing, skin care, and occasional incontinence. He needed help in the shower because he could not reach certain areas. He needed help with dressing because he could not do the lower body. When he had diarrhea from service-connected IBS, he needed help cleaning up because he didn't make it to the toilet. He needed help to be steady. See March 2020 CAPRI. (11) The Veteran's 2020 report that it was difficult just to stand. He needed an assistive device to move. He had been in a wheelchair for over a decade. He could not bend forward. He needed someone to help him stand up. He was a fall risk and had needed people to catch him before. He needed assistance based on issues with the service-connected back, neck, and knee disabilities. He needed help applying medication to the groin area. He could not go to appointments alone and needed help with showering and dressing. Because of service-connected IBS, he had to carry extra clothes with him. He could not pick up stuff and could not sit all day. If he fell on the ground, he could not get up. Further information is provided. See Hearing Transcript. (12) Medical records from 2014 showing that the Veteran needed help with bathing, dressing, using the toilet, moving around indoors, and needed help with his wheelchair. Medical records from 2015 showed difficulty with medication management, using the phone, managing finances, etc. Medical records from 2015 and 2016 showed the need for assistance with bathing, dressing, and incontinence care due to occasional episodes of diarrhea due to service-connected IBS. He needed help with skin care, was mostly wheelchair bound, did not walk much with a cane, and needed help with transfers. See March 2016 CAPRI. (13) Medical records from 2013 showing the need for help with bathing. See February 2014 CAPRI. (14) The Veteran's 2013 report that he could no longer plan on leaving home because of his unpredictable service-connected IBS. The Veteran had a special bed, had oxygen to help him breathe, and needed a motorized wheelchair to get around. The Veteran's service-connected degenerative disabilities stopped the Veteran from being able to walk and required help to shower and dress. See November 2013 Correspondence; September 2013 VA 21-4142. (15) All other relevant lay and medical evidence. A complete and clear rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions. The Veteran and others are competent to attest to factual matters of which they have first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran and/or others, the examiner should provide a fully reasoned explanation. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community or the limits of the examiner's medical knowledge. 4. Readjudicate the issues on appeal. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Dougan, 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.