Citation Nr: 21006928 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 20-09 657 DATE: February 8, 2021 ORDER Entitlement to an effective date prior to November 19, 2018, for the award of service connection for irritable bowel syndrome (IBS) with gastroesophageal reflux disease (GERD) is denied. Entitlement to an effective date prior to November 19, 2018, for the award of service connection for degenerative arthritis of the spine is denied. Entitlement to an effective date prior to November 19, 2018, for the award of service connection for left lower extremity neuropathy is denied. Entitlement to an effective date prior to November 19, 2018, for the award of service connection for right lower extremity neuropathy is denied. Reopening of the claim for service connection for a heart disability is granted; the appeal is granted to this extent only. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include as due to service-connected disabilities, is remanded. Entitlement to service connection for a right hip condition is remanded. Entitlement to service connection for a left hip condition is remanded. Entitlement to service connection for atherosclerosis and atrial fibrillation, to include as due to herbicide agent exposure is remanded. Evaluation in excess of 30 percent for irritable bowel syndrome with peptic ulcer, and gastroesophageal reflux disease is remanded. Evaluation in excess of 20 percent for degenerative arthritis of the spine with intervertebral disc syndrome is remanded. Evaluation in excess of 20 percent for right lower extremity neuropathy (sciatic) is remanded. Evaluation in excess of 20 percent for left lower extremity neuropathy (sciatic) is remanded. Evaluation in excess of 10 percent for varicose veins, left popliteal region is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran’s original claim for entitlement to service connection for IBS and GERD was received on November 19, 2018, more than one year after his separation from service. Prior to that date, there were no pending requests for service connection for IBS or GERD that remained unadjudicated. 2. The Veteran’s original claim for entitlement to service connection for a low back disability was received on November 19, 2018, more than one year after his separation from service. Prior to that date, there were no pending requests for service connection for a low back disability that remained unadjudicated. 3. The Veteran was previously denied service connection for left and right lower extremity neuropathy in an unappealed November 2017 rating decision. 4. The Veteran’s claim to reopen the claims for service connection for left and right lower extremity neuropathy was received on November 19, 2018. Prior to that date, there were no pending requests to reopen claims for service connection for left or right lower extremity neuropathy that remained unadjudicated. 5. A rating decision issued in November 2017 denied service connection for a heart disability. The Veteran was notified of his rights but did not appeal or submit new and material evidence during the applicable one-year appellate period. 6. The evidence associated with the claims file subsequent to the November 2017 rating decision was not previously of record and relates to a previously unestablished fact necessary to substantiate the claim of service connection for a heart disability. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to November 19, 2018 for the award of service connection for IBS with GERD have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.114, 3.155, 3.156, 3.400. 2. The criteria for an effective date prior to November 19, 2018 for the award of service connection for a degenerative arthritis of the spine have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.114, 3.155, 3.156, 3.400. 3. The criteria for an effective date prior to November 19, 2018 for the award of service connection for left lower extremity neuropathy have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.114, 3.155, 3.156, 3.400. 4. The criteria for an effective date prior to November 19, 2018 for the award of service connection for right lower extremity neuropathy have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. §§ 3.114, 3.155, 3.156, 3.400. 5. The November 2017 rating decision is final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. 6. New and material evidence sufficient to reopen the claim of service connection for a heart disability has been received. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1959 to March 1980. This matter comes before the Board of Veterans Appeals (Board) on appeal from a February 2019 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2019, the RO granted service connection for IBS with GERD at 30 percent, degenerative arthritis of the spine (low back disability) at 20 percent, and left and right lower extremity neuropathy at 20 percent each. All four grants of service connection were made effective November 19, 2018. The RO also granted reopening of the claim for service connection for a heart disability, and then denied service connection for a heart disability, left and right hip disabilities, and PTSD. In January 2020 the Veteran filed a notice of disagreement as to the effective dates and ratings assigned for IBS with GERD, the low back disability and left and right lower extremity neuropathy, and the denials of service connection for a heart disability, left and right hip disabilities and PTSD. A statement of the case including these issues was provided in February 2020, and the Veteran filed a substantive appeal in March 2020. The Board notes that on the substantive appeal the Veteran and his attorney stated that they were only appealing the ratings assigned for the IBS, low back disability and bilateral lower extremity neuropathy and the denials of service connection. However, the Veteran also marked that he wished to appeal all issues adjudicated in the statement of the case. See Evans v. Shinseki, 25 Vet. App. 7, 10–17 (2011) (stating that the fact that a Veteran only advances specific arguments as to some of the issues cannot be used to limit a substantive appeal to only those issues when the Veteran checked the box to appeal all issues). As the Veteran noted that he wished to appeal all adjudicated issues, the issues of entitlement to earlier effective dates for the awards of service connection for IBS, the low back disability and the left and right lower extremity neuropathy are also on appeal. The Board also notes that the Veteran’s January 2020 notice of disagreement included the effective date assigned for varicose veins. However, neither service connection nor an increased rating for varicose veins was awarded in the February 2019 rating decision. As no effective date was assigned at that time, it is not possible to disagree with the effective date assigned for that issue. Thus, while the issue of entitlement to an earlier effective date for varicose veins was not included on the statement of the case, remand is not warranted as the question of the appropriate effective date for varicose veins was not adjudicated in the February 2020 rating decision. 38 C.F.R. § 20.201. Claims for psychiatric disability encompass claims for all psychiatric disorders that are reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, the Board has recharacterized the claim on appeal as reflected on the title page. The record reflects that the Veteran’s service-connected disabilities may have prevented him from working during the appeal period. See Correspondence, received November 2020. As a TDIU rating is part and parcel of any claim for an increased rating, and has been expressly raised by the Veteran in this case, it has been added as an issue. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Earlier Effective Dates Unless specifically provided otherwise, the effective date of an award based on a claim for compensation or a reopened claim is to be fixed in accordance with the facts found, but not earlier than the date the claim was received. 38 U.S.C. § 5110(a) (2012). If a claim for compensation is received within one year after separation from service, the effective date for an award of service connection is the day following separation from active service. 38 U.S.C. § 5110 (2012); 38 C.F.R. § 3.400(b)(2) (2018). During the pendency of the appeal the definition of what constitutes a valid claim has changed. Effective March 24, 2015, VA amended its regulations to require that in order to be considered a valid claim, a claim for benefits must be submitted on a standardized form. 79 Fed. Reg. 57,660 (Sept. 25, 2014) (eff. Mar. 24, 2015). However, this amendment only applies to claims or appeals filed on or after March 24, 2015. Id. at 57,686. Under the law prior to the amendment, a claim was defined as a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit. 38 C.F.R. § 3.1(p) (2014) (amended 2015). An informal claim was any communication or action indicating an intent to apply for one or more benefits that identifies the benefit sought. 38 C.F.R. § 3.155(a) (2014) (repealed 2015). Under the law at the time, VA had an obligation to look to all communications from a claimant that may be interpreted as applications or claims—formal and informal—for benefits and was required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). In addition, in cases involving previously denied claims reports of examination or hospitalization from VA or a uniformed service or private medical records may constitute informal claims to reopen. 38 C.F.R. § 3.157(b). Upon receipt of an informal claim for benefits, if a formal claim for benefits had not been filed, VA was required to provide the Veteran with a formal claim form for the Veteran to complete and return. 38 C.F.R. § 3.155(a) (2014). If a formal claim for benefits was then filed within one year of the date the formal claim form was sent to the Veteran, the formal claim was considered to have been filed as of the date of receipt of the informal claim. Id. Following the March 2015 amendment, a claim for benefits must be filed on the standardized claim form prescribed by the Secretary. 38 C.F.R. §§ 3.150, 3.151 (2017). A veteran may also indicate their intent to file a claim for compensation by submitting an intent to file a claim to VA. 38 C.F.R. § 3.155(b) (2017). Upon receipt of the intent to file a claim, VA must provide the claimant with the appropriate claims form. Id. If a complete application for benefits on the form prescribed by the Secretary is received by VA within one year of receipt of the intent to file, VA will consider the formal claim to have been filed as of the date the intent to file a claim was received. Id. An intent to file a claim must be submitted using one of three approved methods and must identify the general benefit and the claimant. Id. 1. Earlier effective dates for the awards of service connection for IBS with GERD and a low back disability. The Veteran filed a claim for service connection for IBS, GERD and a low back disability which was received by VA on November 19, 2018. Service connection was granted for IBS with GERD and a low back disability in the February 2019 rating decision on appeal. See 38 C.F.R. § 4.114 (stating that a single evaluation is to be assigned based on predominant symptoms for disabilities rated under Diagnostic Codes 7301 to 7329 and 7345 to 7348 inclusive). The RO assigned an effective date of November 19, 2018, the date of the formal claim for service connection, for both the IBS with GERD and the low back disability. Prior to the November 19, 2018 formal claim, the Veteran did not file any statements which may be interpreted as expressing an intent to file a claim for service connection that identified, at even a high level of generality, a gastrointestinal disability or low back disability. Sellers v. Wilkie, 965 F.3d 1328, 1337–38 (Fed. Cir. 2020); see also Shea v. Wilkie, 926 F.3d 1362, 1369–70 (Fed. Cir. 2019). No intent to file forms were received within one year prior to receipt of the Veteran’s formal claim on November 19, 2018. 38 C.F.R. § 3.155(b) (2017). While the Veteran had separately filed an earlier claim for service connection for bilateral lower extremity neuropathy, this claim in no way mentioned a low back disability or expressed a desire for disability benefits for a low back disability. As such, the claim for service connection for bilateral lower extremity neuropathy did not give rise to a claim for service connection for a low back disability. Shea, 926 F.3d at 1369–70. As such, the Board finds that the appropriate date of claim in this case is November 19, 2018, the date on which VA received the Veteran’s formal claim requesting service connection for IBS, GERD and a low back disability. As the Veteran’s claim for service connection was received well after the one-year period following his separation from service, the day following the Veteran’s separation from service cannot be used as an effective date. 38 C.F.R. § 3.400(b)(2). As noted earlier, the effective date for an award of service connection is to be fixed based on the facts found, but cannot be earlier than the date the claim was received. 38 U.S.C. § 5110(a) (2012). Here, the Veteran’s claim for service connection for IBS, GERD and a low back disability was received on November 19, 2018. There is no evidence of any claims for service connection for these disabilities prior to that date, and the Veteran and his representative have not presented any argument as to why an earlier date is warranted. As such, the claim for an effective date earlier than November 19, 2018, for the award of service connection for IBS with GERD and a low back disability is denied. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400. 2. Earlier effective dates for the awards of service connection for left and right lower extremity neuropathy. In this case, the Veteran filed a claim for service connection for left and right lower extremity neuropathy which was received on July 11, 2017. In a rating decision issued in November 2017, the RO denied entitlement to service connection for left and right lower extremity neuropathy, stating that there was no evidence of a nexus between the claimed disabilities and service. The Veteran was notified of the decision and his appellate rights the same month, but did not file a notice of disagreement. 38 C.F.R. §§ 20.201, 20.302. Further, no evidence linking the left or right lower extremity neuropathy to the Veteran’s service was associated with the file during the appellate period, nor were new relevant service department records associated with the file following that decision. 38 C.F.R. § 3.156(b), (c). As such, the November 2017 rating decision is final. 38 C.F.R. § 20.1103. On November 19, 2018, VA received a formal claim for service connection for left and right lower extremity neuropathy, to include as secondary to a newly claimed low back disability. While this claim was phrased as one for service connection, as the same claims were previously and finally denied in November 2017, the claim was one to reopen the claims for service connection for left and right lower extremity neuropathy, regardless of how the issues were characterized on the November 2018 claim. The Board also notes that the November 2018 claim asserted that the left and right lower extremity neuropathy was secondary to a low back disability. However, the assertion of a new theory of causation cannot be the basis for a new claim for benefits; instead, the factual basis of a claim is the diagnosed disease or injury. Boggs v. Peake, 520 F.3d 1330, 133437 (Fed. Cir. 2008). Since the underlying disease in this claim is the same as the one denied in November 2017, the allegation of a new theory of entitlement does not make the November 2018 a new claim for benefits. Id. Instead, the November 2018 claim is one to reopen the previously denied claims for service connection. In February 2019, the RO reopened the claims and granted service connection for left and right lower extremity neuropathy effective November 19, 2018, the date of the Veteran’s claim to reopen. Prior to receipt of the November 19, 2018 claim, there are no formal claims or statements expressing a desire for service connection for left or right lower extremity peripheral neuropathy or to reopen the previously denied claim. 38 C.F.R. §§ 3.150, 3.151 (2017). Further, no intent to file forms were received within the one year period prior to receipt of the November 19, 2018 formal claim. 38 C.F.R. § 3.155(b) (2017). As such, the appropriate date of claim in this case is November 19, 2018, the date on which VA received the Veteran’s claim to reopen service connection for left and right lower extremity neuropathy. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(r). As noted earlier, the effective date for an award of service connection based on a reopened claim is to be fixed based on the facts found, but cannot be earlier than the date the claim was received. 38 U.S.C. § 5110(a) (2012). Here, the November 2017 rating decision denying service connection for the disabilities became final. The Veteran’s claim to reopen the claims for service connection for left and right lower extremity neuropathy was received on November 19, 2018, and there is no evidence of any claims for service connection or to reopen the previously denied claims for these disabilities prior to November 19, 2018. Neither the Veteran nor his representative have presented any argument as to why an earlier date is warranted. As such, the claim for an effective date earlier than November 19, 2018, for the award of service connection for left and right lower extremity neuropathy is denied. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(r). New and Material Evidence Where a claim has been finally adjudicated, a claimant must present new and material evidence to reopen the previously denied claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). New evidence is evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence is evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be either cumulative or redundant of the evidence of record at the time of the last prior final denial and must raise a reasonable possibility of substantiating the claim. Id. New and material evidence received prior to the expiration of the appeal period following a decision, will be considered as having been filled in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). The definitions of the terms “new” and “material” for the purposes of this provision are the same as those discussed above. Voracek v. Nicholson, 421 F.3d 1299, 1304 (Fed. Cir. 2005). If evidence received during the appellate period following a decision is new and material, the claim will remain pending until VA issues another decision re-adjudicating the claim and addressing the new and material evidence. Bond v. Shinseki, 659 F.3d 1362, 1367–68 (Fed. Cir. 2011). New and material evidence is not required to reopen a claim when, at any time after VA issues a decision on a claim, VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim. 38 C.F.R. § 3.156(c). “Relevant” means service records that speak to a matter in issue or in dispute. Kisor v. Wilkie, 969 F.3d 1333, 1341–43 (Fed. Cir. 2020). In other words, to be relevant the new service department records must pertain to the basis of the prior final denial. Id. For the purposes of reopening a claim, newly submitted evidence is generally presumed to be credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). New and material evidence is not required as to each previously unproven element of a claim in order to reopen. Shade v. Shinseki, 24 Vet. App. 110, 120 (2010). There is a low threshold for determining whether evidence raises a reasonable possibility of substantiating a claim. Id. at 117–18. 3. Reopening of the claim for service connection for a heart disability. The RO last reopened and then denied service connection for a heart disability in November 2017. The Veteran was notified of the decision but did not file a notice of disagreement. 38 C.F.R. §§ 20.201, 20.302 (2017). No evidence linking the claimed heart disability to the Veteran’s period of service was associated with the file during the applicable one-year appellate period, and no new, relevant service department records have been associated with the file since the November 2017 rating decision. 38 C.F.R. § 3.156(b), (c); see Lang v. Wilkie, 971 F.3d 1348, 1353–55 (Fed. Cir. 2020); see also Kisor v. Wilkie, 969 F.3d 1333, 1341–43 (Fed. Cir. 2020). Therefore, the November 2017 decision became final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. The evidence of record in November 2017 consisted of VA and private treatment records, service treatment and personnel records, and VA examination reports. The evidence failed to show that the Veteran had a heart disability which may be presumed to be exposed to herbicide agent exposure, and that the diagnosed heart disabilities were causally related to the Veteran’s service. Evidence received since the rating decision includes private treatment records and examinations. Of particular note, the private treatment records indicate that the Veteran may have a diagnosis of ischemic heart disease, specifically coronary artery disease. The evidence provided by the Veteran is new as it was not previously submitted to agency decision makers and is material as it addresses the previously unestablished fact of a diagnosis of ischemic heart disease. It is not redundant and raises a reasonable possibility of substantiating the claim. Therefore, reopening of the claim for service connection for a heart disability is warranted. REASONS FOR REMAND 1. Entitlement to service connection for a psychiatric disability. The Veteran submitted a November 2020 private psychiatric evaluation providing a diagnosis of bipolar disorder. Further, the examination report contained an opinion indicating that the psychiatric disability was either related to the Veteran’s period of service or alternatively was caused or aggravated by his other service connected disabilities. Based on the foregoing, a remand is warranted so that the Veteran can be provided with a VA examination to determine the nature and etiology of his claimed psychiatric disability. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see McLendon v. Nicholson, 20 Vet. App. 79 (2006). 2. Entitlement to service connection for left and right hip disabilities. In this case, the Veteran has reported symptoms indicative of left and right hip disabilities, specifically joint pain. Further, the Veteran’s retirement examination notes a history of bilateral hip pain, and the Veteran has indicated that his pain has been persistent since service. Based on the foregoing, a remand is warranted so that the Veteran can be provided with a VA examination to determine the nature and etiology of his claimed left and right hip disabilities. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see McLendon, 20 Vet. App. 79. 3. Entitlement to service connection for a heart disability. The Veteran contends his heart disability is due to herbicide agent exposure in service. The evidence of record reflects that the Veteran was stationed at Nakhon Phanom Royal Thai Air Force Base (RTAFB) as a security policeman assigned to the military dog unit. The Veteran has asserted that he was exposed to herbicide agents while patrolling the perimeter of the base. However, the RO has not yet attempted to verify the Veteran’s claimed exposure to herbicide agents while serving at Nakhon Phanom RTAFB. As such, on remand the RO should make appropriate attempts to verify the Veteran’s exposure to herbicide agents while stationed at Nakhon Phanom RTAFB between July 1971 and July 1972. Further, an opinion concerning the etiology of the Veteran’s heart disability was obtained in in August 2017. The examiner provided a negative opinion, stating that the Veteran did not have a diagnosis of ischemic heart disease and therefore that the diagnosed disabilities of arteriosclerotic heart disease, valvular heart disease and atrial fibrillation were not due to herbicide agent exposure. However, the opinion appears to solely rely on the fact that the diagnosed heart disabilities are not presumed to be related to herbicide agent exposure, rendering the opinion inadequate. Stefl v. Nicholson, 21 Vet. App. 120 (2007); see Combee v. Brown, 34 F.3d 1039, 1043–44 (Fed. Cir. 1994). Further, since the examination and opinion the Veteran has submitted private treatment records indicating a possible diagnosis of coronary artery disease. As such, a remand is necessary for a new opinion concerning the nature of the Veteran’s current heart disability and whether or not any disabilities are causally related to his period of service. 4. Entitlement to increased ratings for IBS, a low back disability, bilateral lower extremity neuropathy, and varicose veins. The Board notes that where the evidence indicates that a service-connected disability has worsened since the last VA examination, and that examination is too remote to constitute a contemporaneous examination, a new examination is required. See 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Green v. Derwinski, 1 Vet. App. 121; Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). The Veteran was last afforded VA examinations to assess the severity of his back, legs, and digestive system disabilities in January 2019. In an October 2020 correspondence, the Veteran’s reported the conditions worsening and additional symptoms. Under these circumstances, the Board finds a remand is warranted for current VA examinations. 5. Entitlement to a TDIU. The issue of entitlement to TDIU must also be remanded as it is inextricably intertwined with the issue of increased ratings on appeal. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when the adjudication of one issue could have “significant impact” on the other issue). Therefore, the Board finds it necessary to remand this issue. The matters are REMANDED for the following action: 1. Secure for the record copies of complete updated clinical records of all VA treatment the Veteran has received for the disorders on appeal. 2. Contact the Veteran and request that he submit or authorize for release all private treatment records relevant to his claimed disabilities. For all records authorized for release, if the search for these records is negative the Veteran must be informed in accordance with 38 C.F.R. § 3.159(e). 3. Make appropriate attempts to verify the Veteran’s claimed herbicide agent exposure while serving at Nakhon Phanom Royal Thai Air Force Base as a security policeman assigned to the military dog section between July 1971 and July 1972. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s claimed psychiatric disability. The examiner should answer the following: a) Identify all current psychiatric disabilities. b) For any diagnosed disability, is it at least as likely as not (a fifty percent probability or greater) that the psychiatric disability was caused by a service-connected disability? c) If not, is it at least as likely as not (a fifty percent probability or greater) that the psychiatric disability was aggravated (worsened) by a service-connected disability? d) If a diagnosis of PTSD is warranted, is it at least as likely as not (a fifty percent probability or greater) that the PTSD is causally related to a verified in-service stressor? e) For any other psychiatric disability, is it at least as likely as not (a fifty percent probability or greater) that the psychiatric disability is causally related to the Veteran’s active service? In answering questions (b) through (e) above, attention is invited to a November 2020 private opinion indicating that the Veteran’s bipolar disorder is either directly related to his active service or was caused or aggravated by his service-connected disabilities (labelled “VA Examination” – uploaded 11/20/2020). A detailed rationale for the opinion must be provided. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s claimed left and right hip disabilities. The examiner should answer the following: a) Identify all current left and right hip disabilities. b) For all disabilities so identified, is it at least as likely as not (a fifty percent probability or greater) that the left or right hip disability is causally related to the Veteran’s active service? In answering question (b), attention is invited to the Veteran’s November 1979 retirement examination which noted bilateral hip pain (labelled “STR - Medical - Photocopy” – pgs. 12-14 – uploaded 4/5/83). A detailed rationale for the opinion must be provided. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. 6. Obtain an addendum opinion to determine the nature and etiology of the Veteran’s current heart disability. The examiner should opine on the following: a) Does the Veteran have a current diagnosis of ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal’s angina)? If it is determined that a diagnosis of ischemic heart disease is not warranted, the examiner should reconcile this opinion with private treatment records indicating a possible diagnosis of coronary artery disease (labelled “Medical Treatment Record - Non-Government Facility” – pg. 18 – uploaded 10/24/20). b) If a diagnosis other than ischemic heart disease is warranted, is it at least as likely as not any other diagnosed disabilities is directly related to the Veteran’s service, to include exposure to herbicide agents? A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. Obtain an examination to determine the current severity of the Veteran’s IBS with GERD. 8. Obtain an examination to determine the current severity of the Veteran’s low back disability and bilateral lower extremity neuropathy. (a) Report the extent of the symptoms of the low back disability in accordance with VA rating criteria. (b) Test for pain on active motion, passive motion, weightbearing, and non-weightbearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, an explanation must be provided. (c) State whether the examination is taking place during a flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, severity, and/or extent of functional impairment during such flare-ups. (d) Identify and evaluate the severity of all neurologic abnormalities or bowel or bladder impairments associated with the low back disability. 9. Obtain an examination to determine the current severity of the Veteran’s varicose veins. CHRISTOPHER A. WENDELL Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Javed, 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.