Citation Nr: A21020628 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 201119-120630 DATE: December 29, 2021 ORDER Service connection for residuals of right ankle keloid removal is denied. Service connection for a left foot disability is denied. Service connection for a right foot disability is denied. Service connection for disability manifested by facial tic is denied. Service connection for a right knee disability is denied. Service connection for pyelonephritis (claimed as chronic kidney infections) is denied. Service connection for lumbosacral strain status post L1-3 lumbar laminectomy is denied. Service connection for residuals of tuberculosis (TB) is denied. REMANDED Entitlement to service connection for diabetes mellitus type II (DM II), to include as due to exposure to herbicide agents and/or as secondary to service-connected hypertension is remanded. FINDINGS OF FACT 1. The Veteran does not have a current right ankle disability. 2. The evidence persuasively shows that the current diagnosis of degenerative arthritis of the left foot did not have its onset in service, is not presumed to have been incurred during active duty, and is not otherwise related to any active service injury or disease. 3. The evidence persuasively shows that the current diagnoses of minimal healed fracture of the first proximal phalanx, right calcaneal spur, and degenerative arthritis of the right foot did not have onset in service, are not presumed to have been incurred during active duty, and are not otherwise related to any active service injury or disease. 4. The evidence persuasively shows shows that the current diagnosis of lumbosacral strain status post L1-3 lumbar laminectomy did not have its onset in service and is not otherwise related to any active service injury or disease. 5. The Veteran does not have a current right knee disability. 6. The Veteran is not shown to have a present disability manifested by a facial tic. 7. The Veteran does not have a current diagnosis of pyelonephritis. 8. The Veteran does not have a tuberculosis diagnosis due to disease or injury in service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for a left foot disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for a right foot disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for entitlement to service connection for lumbosacral strain status post L1-3 lumbar laminectomy are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303 5. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for entitlement to service connection for a disability manifested by a facial tic have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for pyelonephritis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for entitlement to service connection for tuberculosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Navy from April 1966 to September 1990. This appeal comes before the Board of Veterans' Appeals (Board) from September 2020 and November 2020 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In the September 2020 rating decision, the RO denied service connection for facial tic, left foot condition, lumbosacral strain status post L1-3 lumbar laminectomy, PPD convertor (claimed as residuals of TB), pyelonephritis (claimed as chronic kidney infections), residuals of right ankle keloid removal, right foot condition and right knee pain condition. In the November 2020 rating decision, the RO denied service connection for DM II. The Veteran's VA Form 10182, Decision Review Request: Board Appeal was received in November 2020. The Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decisions on appeal. 38 C.F.R. § 20.301. SERVICE CONNECTION Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases may also be established based upon a legal "presumption" by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. 1. Entitlement to service connection for residuals of right ankle keloid removal. The Veteran seeks service connection for residuals of keloid removal, right ankle. The question for the Board is whether the Veteran has a current right ankle disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran's service treatment records (STRs) show that the Veteran had a keloid removed from his right ankle in September 1974 without evidence of a residual scar or functional impairment. Annual physical exams thereafter repeatedly show no recurrence, scarring or residual right ankle symptoms. The Veteran's post-service treatment records do not show complaints, treatment, or diagnosis for a right ankle disability. Moreover, the Veteran himself has not reported experiencing right ankle symptoms during the appeal period and he has not submitted any medical evidence supporting that he has residuals of right ankle keloid removal. A January 2020 VA Scars examination showed no identifiable scars other than on the low back and chest. As such, the claims file does not show any diagnosis for residuals of the in-service right ankle keloid removal. A threshold requirement for substantiating a claim of service connection is that there must be competent evidence of the present disability for which service connection is sought. In the absence of proof of a current disability, there can be no valid claim for service connection. Boyer v. West, 210 F. 3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As it is not shown by competent evidence that at any time during the pendency of the instant claim the Veteran was found to have a right ankle disability, that threshold requirement is not met. Considering the foregoing, the evidence persuasively weighs against the claim. Therefore, the claim for service connection for residuals of right ankle keloid removal must be denied. 2. Entitlement to service connection for a right foot disability. 3. Entitlement to service connection for a left foot disability. The Veteran seeks service connection for right and left foot disabilities. The question for the Board is whether the Veteran has a current foot disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has current diagnoses of minimal healed fracture of the first proximal phalanx, right calcaneal spur, and degenerative arthritis of the left and right feet, the evidence persuasively weighs against finding that any of the Veteran's currently diagnosed foot disabilities began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran's STRs reveal that the Veteran was determined to have pes planus on entrance to active service. See January 1966 entrance examination. While the Veteran reported an illegible foot condition on his separation Report of Medical History, the Veteran's separation clinical examination revealed that his feet were assessed as normal. The rest of the Veteran's STRs do not show complaints, treatment, or diagnosis for a foot disability. The Veteran's post-service treatment records do not show complaints, treatment, or diagnosis for a foot disability until November 2019, when the Veteran was found to have callus formation and slight decreased sensation in his feet due to diabetic neuropathy. See November 2019 Naval Hospital Pensacola treatment note. With respect to whether the Veteran's current diagnoses of minimal healed fracture of the first proximal phalanx, right calcaneal spur, and degenerative arthritis of the left and right feet are related to active duty service, the claims file contains negative medical opinions. Specifically, the December 2019 VA examiner determined that the Veteran's current left and right foot disabilities are less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that the Veteran reported occasional cramping and tingling of the feet and toes. He reported no other symptoms. The examiner stated that the Veteran's claimed symptoms are related to his degenerative arthritis in both feet which is related to wear and tear over time. The examiner stated that the other incidental findings are unrelated to pes planus or the Veteran's reported toe cramping. The examiner also noted that pes planus was present at the time of entry to active service but found no indication of aggravation as the Veteran's separation examination found the Veteran's feet within normal limits. Notably, the examiner did not find a current diagnosis of pes planus and no other competent evidence reveals a current diagnosis of pes planus. These medical opinions are persuasive and probative as to the issue of whether the Veteran's current left and right foot disabilities are caused by or related to active service as the examiner provided a clear explanation for the medical opinions based on a review of the claims file, evaluation of the Veteran, and general medical expertise as a physician. Although the Veteran believes his current foot disabilities are related to service, he is not competent to provide a nexus opinion in this case. The etiology of his left and right foot disabilities is medically complex, as it requires knowledge of interpreting complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The diagnosis and etiology of minimal healed fracture of the first proximal phalanx, right calcaneal spur, and degenerative arthritis of the left and right feet cannot be competently addressed by the Veteran as a lay person based on personal observation, such as, visual observation or by any other senses. The current diagnoses of minimal healed fracture of the first proximal phalanx, right calcaneal spur, and degenerative arthritis of the left and right feet were based on interpretation of symptoms and clinical and diagnostic tests, including x-rays, which requires medical knowledge. Based on the foregoing, the Board finds that the evidence persuasively weighs against showing that the Veteran's current left and right foot disabilities did not have onset in or are otherwise related to active service. Accordingly, service connection for a left or right foot disability is not warranted. 4. Entitlement to service connection for lumbosacral strain status post L1-3 lumbar laminectomy. The Veteran seeks service connection for a back disability. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of lumbosacral strain status post L1-3 lumbar laminectomy, the evidence persuasively weighs against finding that the Veteran's diagnosis of lumbosacral strain status post L1-3 lumbar laminectomy began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran's STRs reveal that the Veteran reported experiencing "occasional low back discomfort" on separation. The Veteran's spine and other musculoskeletal were assessed as normal. The rest of the Veteran's STRs do not show complaints, treatment, or diagnosis for a back disability. During a November 1990 VA examination, the Veteran reported experiencing lower back pain when doing heavy lifting. The VA examiner provided a diagnosis of occasional mild lumbosacral strain. Notably, the next documented complaint or treatment for a back disability was in December 2005 when the Veteran reported chronic back pain. An MRI was performed which revealed osteopenia but no evidence of degenerative disc disease. The next documented complaint or treatment for a back disability was in January 2011 when the Veteran reported a two-week history of worsening low back pain. He was diagnosed with lumbar spine epidural abscess and underwent lumbar spine surgery. With respect to whether the Veteran's current lumbosacral strain status post L1-3 lumbar laminectomy is related to active duty service, the claims file contains negative medical opinions. Specifically, the December 2019 VA examiner determined that the Veteran's current lumbosacral strain status post L1-3 lumbar laminectomy is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner acknowledged that the Veteran reported low back stiffness on separation from active service but stated that such a complaint is non-specific and, given the normal physical separation examination, does not constitute competent medical evidence of a lumbar spine disorder. The examiner stated that the Veteran was first diagnosed with a lumbar spine disability more than a decade after separation from active duty. The examiner stated that peer-reviewed medical literature does not support a nexus between lumbar spine epidural abscess (an acute disorder) that occurred in 2011 more than 10 years after the Veteran's separation from active service and non-specific complaint of low back stiffness. The examiner reiterated that, reasonably speaking, it is not within medical possibility. An additional VA examination and medical opinion were provided in January 2020. The VA examiner determined that the Veteran's current lumbosacral strain status post L1-3 lumbar laminectomy is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner recounted the relevant medical history and stated that it suggests that the current lumbar strain is not due to active service events but from the Veteran's laminectomy. Together, these medical opinions are persuasive and probative as to the issue of whether the Veteran's current lumbosacral strain status post L1-3 lumbar laminectomy is caused by or related to active service as the examiners provided a clear explanation for the medical opinions based on a review of the claims file, evaluation of the Veteran, and general medical expertise as physicians. Although the Veteran believes his current back disability is related to heavy lifting during service, he is not competent to provide a nexus opinion in this case. The etiology of lumbosacral strain status post L1-3 lumbar laminectomy is medically complex, as it requires knowledge of interpreting complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The diagnosis and etiology of lumbosacral strain status post L1-3 lumbar laminectomy cannot be competently addressed by the Veteran as a lay person based on personal observation, such as, visual observation or by any other senses. The current diagnosis of lumbosacral strain status post L1-3 lumbar laminectomy was based on interpretation of symptoms and clinical and diagnostic tests, which requires medical knowledge. Based on the foregoing, the Board finds that the evidence persuasively shows that the Veteran's lumbosacral strain status post L1-3 lumbar laminectomy did not have its onset in or is otherwise related to active service. Accordingly, service connection for a back disability is not warranted. 5. Entitlement to service connection for a right knee disability. The Veteran seeks service connection for right knee pain/right knee disability. The Veteran has not offered a specific statement on whether he alleges he has a current diagnosis of right knee pain/right knee disability that onset in service or that was otherwise caused by his service. The question for the Board is whether the Veteran has a current right knee disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran's STRs reveal that the Veteran reported experiencing "occasional ache in [right] knee area" on separation. The Veteran's lower extremities and spine and other musculoskeletal were assessed as normal. The rest of the Veteran's STRs do not show complaints, treatment, or diagnosis for a right knee disability. The Veteran's post-service treatment records do not show complaints, treatment, or diagnosis for a right knee disability or right knee pain. Moreover, the Veteran himself has not reported experiencing right knee pain or functional impairment during the appeal period. As such, the claims file does not show any diagnosis for a right knee disability. The Veteran has not submitted any lay or medical evidence indicating that he has a right knee disability. His medical records do not show a diagnosis of any such disability or disorder. A threshold requirement for substantiating a claim of service connection is that there must be competent evidence of the present disability for which service connection is sought. In the absence of proof of a current disability, there can be no valid claim for service connection. Boyer v. West, 210 F. 3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As it is not shown by competent evidence that at any time during the pendency of the instant claim the Veteran was found to have a right knee disability, that threshold requirement is not met. The United States Court of Appeals for the Federal Circuit has clarified that pain alone resulting in functional impairment of earning capacity can satisfy the current disability requirement for service connection. Saunders, 886 F. 3d at 1367-68. In this case, as noted above, the Veteran has not reported that he currently experiences any right knee pain or functional impairment and medical records during the appeal period consistently indicate normal musculoskeletal examinations with regard to the right knee. Thus, the Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). Considering the foregoing, the evidence persuasively weighs against the claim. Therefore, the claim for service connection for a right knee disability must be denied. 6. Entitlement to service connection for pyelonephritis (claimed as chronic kidney infections). The Veteran seeks service connection for pyelonephritis (claimed as chronic kidney infections). The Veteran has not offered a specific statement on whether he alleges he has a current diagnosis of pyelonephritis that onset in service or a current diagnosis of pyelonephritis that was otherwise caused by his service. The question for the Board is whether the Veteran has a current kidney disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Veteran's STRs do not show complaints, treatment, or diagnosis for a chronic kidney disability. The Veteran's post-service treatment records reflect that the Veteran was hospitalized for 3 days and treated for pyelonephritis in December 2001. The treating physician wrote a note indicating that the Veteran will need to take antibiotics and stay home for a week following discharge. A December 2001 renal ultrasound was normal and did not indicate any structural renal abnormality. No other post-service medical records show complaints, treatment, or diagnosis for pyelonephritis or residuals of pyelonephritis. Moreover, the Veteran himself has not reported experiencing chronic kidney infections during the appeal period. As such, the claims file does not show any diagnosis for pyelonephritis. The Veteran has not submitted any medical evidence supporting that he has a chronic kidney disability. His medical records do not show a diagnosis of any such disability or disorder. A threshold requirement for substantiating a claim of service connection is that there must be competent evidence of the present disability for which service connection is sought. In the absence of proof of a current disability, there can be no valid claim for service connection. Boyer v. West, 210 F. 3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As it is not shown by competent evidence that at any time during the pendency of the instant claim the Veteran was found to have a chronic kidney disability, that threshold requirement is not met. Considering the foregoing, the evidence persuasively weighs against the claim. Therefore, the claim for service connection for pyelonephritis must be denied. 7. Entitlement to service connection for a disability manifested by facial tic. The Veteran seeks service connection for a disability manifested by facial tic. The Veteran has not offered a specific statement on whether he alleges he has a current disability manifested by facial tics that onset in service or was otherwise caused by his service. The Veteran's STRs reveal that the Veteran reported experiencing "occasional twitching of eyelids or musculature" on separation. Clinical neurologic evaluation was normal. The rest of the Veteran's STRs do not show complaints, treatment, or diagnosis for facial tics or any disability manifested by facial tics. The Veteran's post-service treatment records do not show complaints, treatment, or diagnosis for any disability manifested by facial tics. Moreover, the Veteran himself has not reported experiencing facial tics during the appeal period. As such, the claims file does not show any diagnosis for a disability manifested by facial tics. The Veteran has not submitted any lay or medical evidence supporting that he has a disability manifested by facial tics. His medical records do not show a diagnosis of any such disability or disorder. While the Veteran is competent to describe experiencing facial tics, he has not done so here. A threshold requirement for substantiating a claim of service connection is that there must be competent evidence of the present disability for which service connection is sought. In the absence of proof of a current disability, there can be no valid claim for service connection. Boyer v. West, 210 F. 3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As it is not shown by competent evidence that at any time during the pendency of the instant claim the Veteran was found to have a disability manifested by a facial tic, that threshold requirement is not met. The Board acknowledges the Court's holding in Saunders but does not find a basis for determining that there is functional impairment related to any diagnosis of disability manifested by a facial tic. See Saunders v. Wilkie, 886 F.3d. 1356 (2018). Moreover, the Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). Considering the foregoing, the evidence persuasively weighs against the claim. Therefore, the claim for service connection for a facial tic must be denied. 8. Service connection for PPD convertor (claimed as residuals of TB) remains denied. The Veteran generally asserts that he has residuals of TB that are related to his period of active service. In his November 2019 VA Form 21-526EZ (Application for VA disability benefits), the Veteran indicated that he was applying for VA benefits related to residuals of TB. The application did not contain any additional detail with regard to his claimed residuals of TB. The Veteran's STRs indicate that he tested positive for exposure to TB in 1969 without any evidence of active TB. He was treated for one year with INH therapy and had repeated follow ups which included several chest x-rays and laboratory testing which were all within normal limits. While the Veteran reported blood streaked sputum and loss of weight over the past year, diagnostic testing revealed no lung abnormalities and the Veteran's symptoms were attributed to nasal polyps. See October 1971 STR. A review of the Veteran's post-service medical records shows no diagnosis or treatment for TB. Based on the above, the record does not show that the Veteran has a current TB diagnosis or had a TB disease during the pendency of the claim. His STRs indicate that he had a positive PPD, but no active TB disease. He was prescribed prophylactic medication based on the PPD screen, but again, this was prescribed to counteract any potential disease, because the medical evidence clearly shows no TB symptoms were present at any time during service. Following the positive skin test, the Veteran took medication, never had any symptoms in service, and participated in regular TB screenings. This evidence does not amount to a diagnosis of TB disease or presence of a disability. A positive PPD indicates that the Veteran was infected with the bacteria that causes TB, but the STRs confirm that he never developed a TB disease because he took prophylactic medicine for a year and never had symptoms consistent with an active TB disease. A medical diagnosis of TB disease is still required to show that the presence of the bacteria that causes TB actually resulted in disease or injury in service. Here, the Veteran was not shown to have TB disease in service or following service. He was treated prophylactically following a positive test, but at no time during service did the Veteran contract TB disease. The finding that the Veteran's in-service treatment was prophylactic is further supported by the fact that the Veteran never had TB symptoms in service. Moreover, post-treatment in-service chest x-rays were normal with no indication of history of TB disease. Further, the Veteran's VA treatment records indicate that he was not diagnosed with TB disease at any time since service. The Veteran, as a lay person, is competent to report observable symptoms. See Barr v. Nicholson, 21 Vet. App. 303, 308-310 (2007). However, the Veteran does not have medical expertise to opine as to the current nature and likely etiology of a diagnosed disability to account for those symptoms. The issue is medically complex, as it requires specialized medical education/knowledge of the interaction between multiple organ systems in the body/the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As such, the Veteran's lay statements cannot serve as a basis for a diagnosis or nexus in this case. Of note, the Veteran was not afforded a VA examination for his claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). According to McLendon, VA must provide a medical examination when there is evidence of (1) a current disability, (2) an in-service event, injury, or disease, (3) some indication that the claimed disability may be associated with the established event, injury, or disease, and (4) insufficient competent evidence of record for VA to make a decision. The third prong, which requires evidence that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. Here, the record does not show an in-service disease or injury. As noted above, the Veteran had a positive PPD screen in service but he never developed TB disease or any symptoms that could be attributable to TB disease. Accordingly, there is no indication that an in-service disease occurred. As previously noted, a positive PPD only indicates the presence of the bacteria that causes the TB disease, and the evidence shows that the Veteran did not contract the TB disease in service. The Veteran's in-service treatment was prophylactic as he did not have any symptoms, was regularly screened, and had normal chest x-rays. Without evidence of an in-service event, injury, or disease, a VA examination is not warranted under the standards of McLendon. In sum, the probative medical evidence of record indicates that the Veteran does not have a current diagnosis of TB disease due to disease or injury in service. Accordingly, service connection is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for DM II, to include as due to exposure to herbicide agents and/or as secondary to service-connected hypertension is remanded. The Veteran contends that he has DM II that is related to his period of active service, to include in-service herbicide agent exposure and/or as secondary to his service-connected hypertension. The Veteran was provided a VA examination in December 2019. The examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran's DM II is proximately due to or the result of the service-connected hypertension. The examiner stated that the claimed disorder is a separate entity entirely from the service connected condition and unrelated to it. The examiner stated that the medical literature does not support a medical relationship and thus a nexus has not been established. The examiner explained that research does not indicate that hypertension causes diabetes. The examiner acknowledged that hypertension is common among patients with DM2 and that research indicates hypertension is a strong risk factor for ASCVD, heart failure, and vascular diseases but stated that DM II is not a strong risk factor for diabetes. The examiner explained that diabetes is a chronic condition that affects the way the body processes blood sugar and that hypertension is a chronic medical condition in which the blood pressure in the arteries is persistently elevated. Thus, the examiner concluded, the Veteran's service-connected hypertension did not cause his DM II. Unfortunately, the opinion is inadequate for adjudication purposes. While the examiner discussed secondary causation, she did not provide an opinion as to aggravation of the Veteran's DM II by the service-connected hypertension. When VA undertakes to obtain an examination, it must ensure that the examination and opinion therein is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The United States Court of Appeals for Veterans Claims (Court) has indicated that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b). El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). This is a pre-decisional duty to assist error requiring remand. An addendum opinion, with adequate rationale, on whether the Veteran's DM II was aggravated by his service-connected hypertension is necessary; therefore, a remand is in order. The matters are REMANDED for the following action: 1. Obtain a medical opinion for the service connection claim for DM II from an appropriate medical specialist. Only arrange for the Veteran to undergo an examination if deemed necessary in the judgment of the medical specialist designated to provide the medical opinion. The entire, electronic claims file to include a complete copy of this REMAND must be made available to the designated individual, and the medical opinion report should include discussion of the Veteran's documented history and assertions. If the Veteran is examined, all indicated tests and studies should be accomplished (with all results made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. The medical specialist is requested to address or provide an opinion as to whether it is at least as likely as not that the Veteran's DM II is related to, or aggravated (made worse beyond natural progression) by the Veteran's service-connected hypertension. If the Veteran's DM II is aggravated by his service-connected hypertension, the examiner should also indicate, to the extent possible, the degree of such aggravation by identifying the baseline level of disability. If an opinion cannot be offered without resorting to speculation, the examiner should so state and explain why a non-speculative opinion cannot be offered. Mike Sobiecki Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Victor Modesto 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.