Citation Nr: 21077168 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 12-16 534 DATE: December 28, 2021 ORDER Entitlement to service connection for chronic constipation is dismissed. Entitlement to service connection for hemorrhoids is dismissed. Entitlement to service connection for diabetes mellitus as due to medications prescribed to treat service-connected hypertension is granted. Entitlement to service connection for gout as due to medications prescribed to treat service-connected hypertension is granted. Entitlement to service connection for gastroesophageal reflux disease (GERD), including as due to in-service environmental exposures and service-connected hypertension or the medications prescribed to treat it, is denied. Entitlement to service connection for a sinus disorder, to include sinusitis and rhinitis (claimed as watery eyes), including as due to in-service environmental exposures and service-connected hypertension or the medications prescribed to treat it, is denied. Entitlement to service connection for a sebaceous cyst, to include as due to a medically unexplained chronic multi symptom illness (MUCMI), is denied. Entitlement to a disability rating greater than 10 percent for degenerative joint disease of the right knee is denied. Entitlement to a disability rating greater than 10 percent for right knee, status post anterior cruciate ligament (ACL) reconstruction, is denied. REMANDED Entitlement to service connection for a disability manifested by noncardiac chest pain, to include as secondary to in-service asbestos exposure or service-connected hypertension, is remanded. FINDINGS OF FACT 1. In January 2021, prior to the promulgation of a decision in the appeal, the Regional Office (RO) granted service connection for irritable bowel syndrome, constipation dominant, and for internal hemorrhoids. 2. Resolving any reasonable doubt in the Veteran's favor, the record evidence shows that his diabetes mellitus and gout are aggravated by medications taken to treat his service-connected hypertension. 3. The record evidence shows that the Veteran's GERD and sinus disorder are not related to active service or any incident of service, to include in-service environmental exposure, and were not caused or aggravated by service-connected hypertension. 4. The record evidence shows that the Veteran's cyst has a known etiology and clear diagnosis but is not related to an in-service injury or disease to include in-service environmental exposure or as part of a MUCMI. 5. The record evidence shows that the Veteran's right knee status post ACL reconstruction is manifested by a symptomatic removal of the cartilage. 6. The record evidence shows that the Veteran's right knee degenerative joint disease is manifested, at worst, by flexion to 125 degrees and a slight impairment of the knee. CONCLUSIONS OF LAW 1. The criteria for dismissal of the appeal for service connection for chronic constipation and for hemorrhoids have been met. 38 U.S.C. § 7105 (2020). 2. The criteria for service connection for diabetes mellitus as due to medications prescribed to treat service-connected hypertension have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 3. The criteria for service connection for gout as due to medications prescribed to treat service-connected hypertension have been met. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 4. The criteria for service connection for GERD, including as due to in-service environmental exposures and service-connected hypertension or the medications prescribed to treat it, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 5. The criteria for service connection for a sinus disorder, to include sinusitis and rhinitis, including as due to in-service environmental exposures and service-connected hypertension or the medications prescribed to treat it, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 6. The criteria for service connection for a sebaceous cyst due, including as due to a MUCMI, have not been met. 38 U.S.C. §§ 1110, 1117, 1118, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310, 3.317 (2020). 7. The criteria for a disability rating greater than 10 percent for right knee denigrative joint disease have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.71a, Diagnostic Code (DC) 5257-5003 (2020). 8. The criteria for a disability rating greater than 10 percent for right knee, status post ACL reconstruction, have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.71a, DC 5299-5259 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the U.S. Army from July to November 1980, January 1987 to January 1990, and from May 1994 to September 1994. He also served in the U.S. Air Force from November 2001 to March 2002 and from January 2003 to August 2003. These matters come before the Board of Veterans' Appeals (Board) on appeal from June 2009, December 2010, and November 2013 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office. This case was before the Board previously in July 2017 and August 2019 when it was remanded for further development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Dismissed Claims This appeal was certified to the Board in July 2017. Service connection for the Veteran's claimed chronic constipation and hemorrhoids subsequently was awarded by the RO in a January 2021 rating decision. As such, there remains no case or controversy regarding these issues. 38 U.S.C. § 7105; see also Baughman v. Derwinski, 1 Vet. App. 563, 566 (1991). Thus, the Board does not have jurisdiction to review these claims and they are dismissed. 1. Entitlement to service connection for diabetes mellitus and gout, each as due to medications prescribed to treat service-connected hypertension The Veteran alleges his diabetes mellitus and gout are due to his service-connected hypertension or the medications prescribed to treat these disabilities. In regard to current disability, August 2017 VA examinations indicate that the Veteran has current diagnoses of diabetes mellitus and gout. Thus, the first element of service connection has been established. With respect to diabetes mellitus, in regard to an in-service diagnosis, the Veteran's service treatment records show no complaint, finding, or diagnosis related to diabetes mellitus. The Board notes that the absence of contemporaneous records does not preclude granting service connection for a claimed disability. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding lack of contemporaneous medical records does not serve as an "absolute bar" to the service connection claim); Barr v. Nicholson, 21 Vet. App. 303 (2007) ("Board may not reject as not credible any uncorroborated statements merely because the contemporaneous medical evidence is silent as to complaints or treatment for the relevant condition or symptoms"). With respect to gout, in regard to an in-service diagnosis, the Veteran also contends that in-service environmental exposures while deployed to the southwest Asia theater of operations caused or contributed to his gout. His service treatment records include no complaint, finding, or diagnosis related to gout. He has not alleged experiencing symptoms of gout during service. This is not necessarily fatal to his claim. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. The record shows that he worked in pest control and had service in Saudi Arabia from November 2001 to March 2002. Thus, the Board concedes that the in-service element of environmental exposures while deployed to the southwest Asia theater of operations has been established. The question remains whether there is a medical nexus between diabetes mellitus or gout and a service-connected disability sufficient to support granting service connection for either of these disabilities on a secondary basis. See 38 C.F.R. § 3.310. With regard to a nexus between a service-connected disability and the Veteran's diabetes mellitus or gout, the evidence conflicts. On the one hand, in August 2017, the Veteran was afforded a VA examination. The examiner reviewed the Veteran's file and opined it is less likely as not that the Veteran's diabetes mellitus or gout is related to his service-connected hypertension. The examiner stated that the diabetes and hypertension and gout and hypertension are not medically related and the medical literature does not support a relationship. This examiner also opined that it is less likely than not that the Veteran's gout is related to in-service environmental exposures while deployed to the southwest Asia theater of operations. The examiner also stated that there is no medical literature to support finding that gout is related to environmental contaminants. On the other hand, the Veteran was afforded another VA examination in January 2020. The examiner opined the Veteran's diabetes mellitus is not at least as likely as not proximately due to or the result of his service-connected hypertension or the medications taken for it. The examiner also opined the Veteran's gout is not at least as likely as not aggravated by his service-connected hypertension or the medications taken for it. This examiner conceded that the medication taken by the Veteran for hypertension, hydrochlorothiazide, was a risk factor for developing diabetes mellitus, but the Veteran's low dosage was less of a factor than his family genetics. Further, the examiner stated that the medical science does not support that essential hypertension in itself aggravates diabetes mellitus or gout; however, the hyperglycemic effect of the anti-hypertensive medication, hydrochlorothiazide, should resolve once the medication is discontinued and thus would not be permanent aggravation of either diabetes mellitus or gout. The Board notes here that the January 2020 VA examiner applied an incorrect standard for secondary aggravation (permanent aggravation). Under Ward v. Wilkie, 31 Vet. App. 233 (2019), any amount of aggravation is sufficient to establish secondary service connection and permanent aggravation/worsening of a non-service-connected disability is not required. The January 2020 examiner concluded that essential hypertension does not aggravate diabetes mellitus by itself. Critically, this examiner also suggested that the medication taken by the Veteran to treat his service-connected hypertension aggravated his diabetes mellitus and his gout. The Board finds that the evidence is in relative equipoise regarding the question of whether the Veteran's service-connected hypertension or the medications prescribed to treat it aggravated his diabetes mellitus and gout. On the one hand, the August 2017 VA medical opinion weighs against the Veteran's claims. On the other hand, the January 2020 opinion supports the claims. In summary, and after resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for diabetes mellitus and gout, each as due to medications prescribed to treat service-connected hypertension, is warranted. 2. Entitlement to service connection for GERD including as due to in-service environmental exposures and service-connected hypertension or the medications prescribed to treat it The Veteran essentially contends that his current GERD is related to in-service environmental exposures or alternatively is due to his service-connected hypertension or the medications prescribed to treat it. With regard to a present disability, the Veteran was diagnosed with GERD following a September 2010 endoscopy. An August 2017 VA examination notes a diagnosis of GERD was established in 2013. Thus, the first element of service connection has been established. In regard to an in-service diagnosis, the service treatment records include no complaint, finding, or diagnosis related to GERD. This is not necessarily fatal to his claim. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. He also contends that environmental exposures experienced while deployed to the southwest Asia theater of operations caused or contributed to his GERD. As discussed above, the Board has conceded in-service environmental exposures. The record evidence shows that the Veteran served in the Persian Gulf and service connection is in effect for multiple disabilities encompassed under a MUCMI. The August 2017 VA examiner opined that GERD is not an undiagnosed illness and is a diagnosable disorder with a clear and specific diagnosis. Thus, it cannot be considered part of a MUCMI. The examiner also opined that GERD does not occur secondary to environmental conditions. In January 2020, a second VA examiner opined that the Veteran's GERD was less likely than not manifested during service or otherwise related to his periods of active duty service to include environmental exposures while stationed in the Persian Gulf. The examiner stated that the current medical literature and current VA research do not link the development of or aggravation of GERD to Persian Gulf exposures. Further, GERD is a diagnosed illness with a partially understood etiology. Thus, the Board finds that the preponderance of the evidence weighs against finding a direct nexus between the Veteran's active service, to include environmental contaminate exposure, and his current diagnosis of GERD. Without evidence of a nexus, direct service connection is not warranted. The question remains whether there is a nexus between the GERD and service-connected hypertension sufficient to support granting secondary service connection. See 38 C.F.R. § 3.310. In January 2020, a VA examiner opined that it is less likely than not that the Veteran's GERD was proximately due to or aggravated by his service-connected hypertension to include medications taken to treat it. The examiner noted that the specific medications prescribed to the Veteran are not specifically known to cause GERD or known as a significant cofactor in the development or aggravation of GERD. The Board notes that the Veteran believes his GERD is proximately due to or aggravated beyond its natural progression by his exposure to environmental contaminants or alternatively his service-connected hypertension. As a lay person, he is not competent to provide a nexus opinion regarding this issue because it is medically complex and requires knowledge of complex interactions between different bodily systems. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the January 2020 VA examiner's opinion which was fully supported. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In summary, the Board finds that service connection for GERD, including as due to in-service environmental exposures and service-connected hypertension or the medications prescribed to treat it, is not warranted. 3. Entitlement to service connection for a sinus disorder to include sinusitis and rhinitis (claimed as watery eyes), including as due to in-service environmental exposures and service-connected hypertension or the medications prescribed to treat it The Veteran contends that his current sinus disorder is related to in-service environmental exposures or alternatively to service-connected hypertension or the medications prescribed to treat it. With regard to present disability, the August 2017 VA examination notes a diagnosis of allergic rhinitis. The Veteran also described symptoms of congestion, watery, itchy eyes, and drainage. Thus, the first element of service connection has been established. In regard to an in-service diagnosis, the service treatment records include no complaint, finding, or diagnosis related to a sinus disorder. This again is not necessarily fatal to his claim. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. He also contends that in-service environmental exposures while deployed to the southwest Asia theater of operations contributed to his sinus disorder. As noted elsewhere, the Board has conceded in-service environmental exposures. In January 2020, a VA examiner opined that the Veteran's sinus disorder was less likely than not manifested during service or otherwise related to his periods of active-duty service to include the environmental exposures while stationed in the Persian Gulf. The examiner stated that allergic rhinitis, with which the Veteran has been diagnosed, is caused by exposure to allergens and is not specific to a Gulf War chemical. Thus, the Board finds that the preponderance of the evidence weighs against finding a direct nexus between the Veteran's active-duty service, to include environmental exposures while deployed to the southwest Asia theater of operations, and his current diagnosis of a sinus disorder. Without evidence of a nexus, service connection is not warranted on a direct basis. The question remains whether there is a nexus between the sinus disorder and service-connected hypertension sufficient to support a finding of secondary service connection. The record evidence shows that, in January 2020, a VA examiner opined that it is less likely than not that the sinus disorder was proximately due to or aggravated by his service-connected hypertension to include medications taken to treat his hypertension. The examiner noted that the specific medications prescribed to the Veteran are not specifically known to cause any sinus disorders or known as a significant cofactor in the development or aggravation of a sinus disorder. The Board notes that the Veteran believes his sinus disorder is proximately due to or aggravated beyond its natural progression by his exposure to environmental contaminants or alternatively his service-connected hypertension. As a lay person, he is not competent to provide a nexus opinion regarding this issue because it is medically complex and requires knowledge of complex interactions between different bodily systems. See Jandreau, 492 F.3d 1372, 1377 n.4; see also Kahana, 24. Vet. App. at 428. Thus, the Board gives more probative weight to the January 2020 VA examiner which was fully supported. See Stefl, 21 Vet. App. at 124. The Veteran otherwise has not identified or submitted any evidence demonstrating his entitlement to service connection for a sinus disorder, including as due to in-service environmental exposures and service-connected hypertension or the medications prescribed to treat it. In summary, the Board finds that service connection for a sinus disorder, including as due to in-service environmental exposures and service-connected hypertension or the medications prescribed to treat it, is not warranted. 4. Entitlement to service connection for a sebaceous cyst, to include as due to a MUCMI The Veteran has contended that his history of cysts on his neck is related to in-service environmental exposures or alternatively as part of a MUCMI. With regard to present disability, the August 2017 VA examination notes a diagnosis of a sebaceous cysts of the posterior neck, status-post excision with no residuals. Thus, the first element of service connection has been established. In regard to an in-service diagnosis, the service treatment records include no complaint, finding, or diagnosis related to skin conditions of the neck to include cysts. He has not alleged experiencing symptoms of cysts during service. This again is not necessarily fatal to his claim. See Buchanan, 451 F.3d at 1337, and Barr, 21 Vet. App. at 303. He also has contended that in-service environmental exposures contributed to his sebaceous cysts. As noted above, the Board has conceded in-service environmental exposures. The Veteran served in the Persian Gulf and service connection is in effect for multiple disabilities encompassed under a MUCMI. Nevertheless, the January 2020 VA examiner opined that the Veteran's cyst is not a part an undiagnosed illness and is a diagnosable disorder with a clear and specific diagnosis. This examiner noted that the pathology of the cyst removed from the Veteran's neck in July 2012 was that of an epidermoid cyst which is a benign condition with known causes. Thus, it cannot be considered a part of a MUCMI. The January 2020 VA examiner also opined that the Veteran's cyst was less likely than not manifested during service or otherwise related to his periods of active-duty service to include environmental exposures while in the Persian Gulf. Thus, the Board finds that the preponderance of the evidence weighs against finding a direct nexus between the Veteran's active-duty service, to include environmental exposures, and his current diagnosis of a sebaceous cyst. He otherwise has not identified or submitted any evidence demonstrating his entitlement to service connection for a sebaceous cyst, to include as due to a MUCMI. In summary, the Board finds that service connection for a sebaceous cyst, to include as due to a MUCMI, is not warranted. Increased Rating 5. Entitlement to disability ratings greater than 10 percent for degenerative joint disease of the right knee and for right knee, status post ACL reconstruction The Veteran contends that he is entitled to increased ratings for his service-connected right knee disabilities. He contends that his right knee impairment has worsened throughout the appellate period. The right knee degenerative joint disease is rated under DC 5257-2003. The right knee, status post ACL reconstruction, is rated under DC 5299-5259. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. See 85 Fed. Reg. 230 (Nov. 30, 2020). Therefore, the Board will consider these claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria more favorable to the Veteran will be applied. The record evidence shows that the Veteran was afforded a VA examination in March 2009. The examiner found the Veteran experienced fullness and tenderness of the right popliteal area. Active flexion was to 120 degrees with some pain and extension was normal. There was no change in functional capacity after repetition. There was no evidence of ligamentous instability and strength was 5/5. The examiner noted that the Veteran could have increased knee pain during a flare up that could reduce is functional capacity, but an estimate of additional functional loss could not be given without speculation. In July 2009, the Veteran submitted a statement that he experienced constant pain and daily swelling in the right knee. Further, he stated that the ACL had been removed from his knee and screws placed to stabilize it. In October 2009, private treatment notes indicate the Veteran was treated for a painful knee. X-rays of the right knee showed a previous ACL reconstruction and moderate degenerative joint disease. The knee retained a full range of motion. In July 2010, upon a VA examination of the joints, the Veteran reported no flare ups of the knees. Passive extension showed some mild crepitus, but the Veteran denied pain in the right knee. Range of motion testing showed flexion to 122 degrees and to 124 degrees after repetition. The examiner noted no pain during examination. The Veteran had normal extension and stability was normal. VA Medical Center treatment notes from July 2010 showed the Veteran was treated for chronic pain in the knees. He had a full range of motion of the right knee with pain. Upon VA examination in February 2012, the Veteran had flare ups of the bilateral knees with stiffness occurring two to three times a week whenever he stands for more than 30 minutes or walks more than a quarter of a mile. Range of motion testing showed flexion to 125 with pain beginning at 100 degrees. Extension was normal. No loss of range of motion occurred after repetition. The examiner found the Veteran could have an increase of limitations during a flare up but could not provide an estimate in terms of range of motion limitations without resorting to speculation. The Veteran maintained full muscle strength, normal stability, no history of recurrent patellar subluxation or dislocation, no meniscal disorders, and no additional conditions. In June 2014, a VA examiner opined that upon reviewing the medical evidence there could be a further limitation in the Veteran's functional capacity during times of flare ups; however, these parameters could not be estimated or expressed as additional loss in degree of motion without resorting to speculation. The examiner noted that the Veteran showed no additional limitation of motion after repetitive motion testing, no weakened movement, excess fatigability, and/or incoordination. In August 2014, the Veteran submitted a statement that he wore a knee brace to assist movement and when he stands his legs are uneven. The Veteran stated his right leg hurts from his hip to his foot and it feels numb. Upon VA examination in August 2017, the Veteran reported pain in both knees which was aggravated by walking. He denied flare ups. Range of motion testing showed right knee motion was overall normal with no indication of pain. The right knee did not have any additional factors contributing to disability. Muscle strength testing was normal and there was no evidence of atrophy, recurrent subluxation, history of lateral instability or effusion, stress fractures, or other impairments of the tibia or fibula. Upon VA examination in November 2019, the Veteran reported no flare ups but he could not crawl or move around on his knees without pain. Range of motion testing showed flexion to 125 degrees with no pain on examination. Muscle strength testing and joint stability testing was normal. There was no evidence of ankylosis, recurrent patellar dislocation, or meniscal conditions. The examiner noted the Veteran's 1989 ACL repair. In March 2021, the Veteran requested an examination of his right knee due to constant pain, knee popping, morning stiffness, and his right knee giving way when getting up from sitting for long periods of time. He also stated that he had trouble going up and down stairs without pain. Upon VA examination in May 2021, the Veteran reported flare ups of the right knee occurring daily and lasting two hours. The flare ups were precipitated by walking, moving, bending and were alleviated by rest. Range of motion testing showed a normal range of motion in the right knee with no additional losses after repetitive movement testing. The examiner opined that the Veteran would be limited during periods of flare ups to flexion of 125 degrees due to pain. There was no evidence of ankylosis, and joint stability testing was normal. There were no impairments of the tibia or fibula nor meniscal conditions. The evidence of record demonstrates the Veteran's right knee disability is manifested by, at worst, flexion to 100 degrees with pain and normal extension. Anything greater than 60 degrees of flexion is to be rated noncompensable under DC 5260. Anything less than 5 degrees of extension is to be rated noncompensable under DC 5261. 38 C.F.R. § 4.71a. Accordingly, an increased evaluation is not warranted. The Veteran's right knee instability has not been shown to be worse than a slight lateral instability. Accordingly, an increased evaluation for right knee instability also is not warranted. Finally, the Board notes that the Veteran is in receipt of the highest schedular rating under DC 5259 for removal of cartilage following his ACL reconstruction. The Board has considered the Veteran's reports of bilateral knee instability and popping. During the May 2021 VA examination, right knee joint stability testing was normal without objective evidence of instability. Further, while he has described popping, the objective medical evidence has not shown any history of dislocated semilunar cartilage nor evidence of frequent locking or effusion into the joint. Thus, a separate rating for dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint also is not warranted. The Board recognizes that the Veteran is competent to report symptoms such as pain and limited motion. See Layno, 6 Vet. App. at 465. As a lay person, however, he is not competent to offer a medical opinion as to the relative severity of his right knee disability as doing so requires medical knowledge and expertise he has not been shown to possess. See Kahana, 24 Vet. App. at 435; Buchanan, 451 F.3d at 1336 37. In summary, the Board finds that the criteria for disability ratings greater than 10 percent for right knee degenerative joint disease and for right knee, status-post ACL reconstruction, are not warranted. REASONS FOR REMAND Entitlement to service connection for a disability manifested by noncardiac chest pain, to include as secondary to in-service asbestos exposure or service-connected hypertension The Veteran has alleged that his disability manifested by non-cardiac chest pain is due to in-service exposure to asbestos during periods of service at Pope Air Force Base. He alternatively contends that his service-connected hypertension caused or aggravated his disability manifested by non-cardiac chest pain. On VA examination in August 2017, the VA examiner found that the Veteran's symptoms of chest pain were subjective only and objective examination was normal. Consequently, the examiner did not provide nexus opinions as to the relationship between the non-cardiac chest pain and asbestos exposure, as secondary to hypertension, or as secondary the medications taken to treat hypertension. In Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that service connection may be warranted for complaints of pain which result in functional impairment. The August 2017 VA examiner did not consider whether the Veteran's disability manifested by non-cardiac chest pain resulted in functional impairment. Thus, the Board finds that, on remand, another VA opinion should be obtained which addresses this matter. The matter is REMANDED for the following action: 1. Conduct any appropriate development to obtain the Veteran's updated treatment records. 2. Schedule the Veteran for examination to determine the nature and etiology of his claimed disability manifested by noncardiac chest pain. The claims file and a copy of this REMAND should be provided for review. Based on a review of the claims file and the results of the Veteran's examination, the clinician is asked to state whether the disability manifested by non-cardiac chest pain results in functional impairment. The clinician next is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that a disability manifested by noncardiac chest pain is due to active service, to include in-service asbestos exposure. The clinician also is asked to state whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's service-connected hypertension and/or medications prescribed to treat it caused or aggravated a disability manifested by noncardiac chest pain. A rationale must be provided for any opinion(s) expressed. If any requested opinion(s) cannot be provided without resorting to speculation, then the clinician must explain why this is so. The clinician is advised that the lack of contemporaneous records documenting complaints of or treatment for a disability manifested by noncardiac chest pain, alone, is insufficient rationale for a medical nexus opinion. 3. Readjudicate the appeal. MICHAEL T. OSBORNE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Laura C. Owens 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.