Citation Nr: 21007252 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 18-06 929 DATE: February 9, 2021 ORDER Entitlement to service connection for arthritis (claimed as arthritis of the whole body) is denied. REMANDED Entitlement to service connection for heart condition(s) (claimed as pericarditis and palpitations), to include as due to herbicide-agent exposure, is remanded. Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide-agent exposure, is remanded. Entitlement to service connection for hypertension, to include as due to herbicide-agent exposure; and to include secondary to heart condition(s) and/or diabetes mellitus, type II, is remanded Entitlement to service connection for kidney disease as secondary to heart condition(s) and/or diabetes mellitus, type II, is remanded. Entitlement to service connection for bilateral eye condition(s) (claimed as bilateral partial blindness) as secondary to heart condition(s) and/or diabetes mellitus, type II, is remanded. Entitlement to service connection for gout as secondary to heart condition(s) and/or diabetes mellitus, type II, is remanded. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran had arthritis (claimed as arthritis of the whole body) at any time during or approximate to the pendency of his claim. CONCLUSION OF LAW The criteria for entitlement to service connection for arthritis (claimed as arthritis of the whole body) have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Navy from June 1958 until his honorable discharge in October 1977. This appeal has been advanced on the Board of Veterans’ Appeals’ (Board) docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c). These matters come before the Board on appeal from a September 2015 rating decision by the Oakland, California, Regional Office (RO) of the United States Department of Veterans Affairs (VA), which denied service connection for each of the claimed disabilities addressed within this decision. In October 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ), sitting at the RO in Oakland, California. A transcript of the hearing has been associated with the record on appeal. During the hearing, the undersigned held the record open for 60 days to allow for the submission of additional evidence. Within that timeframe, the Veteran submitted medical correspondence and records. Entitlement to service connection for arthritis (claimed as arthritis of the whole body) is denied. Evidentiary Standards In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. 38 U.S.C. § 7104(a). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. §§ 1154(a); 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 128‒29 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analyses below focus on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a “service connection.” 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. In addition, service connection may be established on a presumptive basis for certain “chronic diseases” that manifest in service or within the presumptive period following separation from service (such that their existence in service is presumed). 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The term “chronic disease” refers to those diseases in 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a). “For the showing of chronic disease in service[,] there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word ‘Chronic.’ ” 38 C.F.R. § 3.303(b). Where a chronic disease is shown in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). In cases where a chronic disease is “shown as such in service,” the Veteran is “relieved of the requirement to show a causal relationship between the condition in service and the condition for which service-connected disability compensation is sought.” Walker, 708 F.3d at 1336. In other words, “there is no ‘nexus’ requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease.” Id. Where the chronic condition is not “shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,” i.e., “when the fact of chronicity in service is not adequately supported,” then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Id. Continuity of symptomatology is established if a veteran demonstrates that a condition was “noted” during service or during the presumptive period, there is evidence of post-service continuity of the same symptoms, and there is evidence of a nexus between the present disability and those symptoms. 38 C.F.R. § 3.303(b). A condition is “noted” where evidence is “indicative of but not dispositive of a chronic disease.” Walker, 708 F.3d at 1336. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed. Id. at 1339. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of, or aggravated by a service-connected disability. 38 C.F.R. §§ 3.310(a), (b). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) a current disability exists, (2) the veteran has a service-connected disability; and (3) the current disability was either (a) proximately due to or the result of; or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Analysis The Board finds there is no competent, credible, or probative evidence that the Veteran has or had arthritis, to exclude gout, in a part of his body during the pendency of his claim. Consequently, without a current disability, the Veteran is not entitled to service connection on a direct or secondary basis, nor is the presumption of service connection under 38 C.F.R.§ 3.309 applicable. In his July 2015 VA application for disability benefits, the Veteran claimed service connection for “arthritis.” He did not expand on his claim. In his February 2016 notice of disagreement with the RO’s September 2015 rating decision, he asserted he had “arthritis all over [his] body.” During his October 2020 Board hearing, the Veteran testified he experienced “pain on [his] knees . . . especially when the weather is kind of cold.” October 2020 Board Hearing Transcript, at 24. He also testified that no doctor had told him that he had arthritis. Id. at 25. He believed he had arthritis and that “everything is tied up to [his] diabetes and heart problem.” Id. The Board acknowledges the Federal Circuit has held that lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson, 581 F.3d at 1316. While the Board finds the Veteran competent to report his sensations of pain, including severity, frequency, and duration, he is not competent to diagnose himself with arthritis without demonstrating that he has the necessary medical training or expertise, nor can he competently opine that his perceived arthritis is caused by his heart condition(s) or diabetes mellitus, type II. See 38 C.F.R. §§ 3.159(a)(1), (2); Jandreau v. Nicholson, 493 F.3d 1372, 1377 (Fed. Cir. 2007) (noting general competence of laypersons to testify as to symptoms but not medical diagnosis). Therefore, the Board does not find the Veteran is competent to establish that he presently has or had arthritis during the pendency of his claim. Moreover, the Board has reviewed the Veteran’s private medical records contained within his claims file and there is no documentation of arthritis prior to the filing of his claim or thereafter. Significantly, February 2015, April 2015, May 2015, and June 2015 medical notes from South Valley Medicine & Cardiology Medical Group, Inc., recorded that the Veteran reported right leg pain, but no diagnosis of arthritis was ever documented or suggested. In each note, the medical professionals documented the Veteran’s past and current medical conditions, which included, among other things, congestive heart failure (diagnosed in 2012), coronary artery disease (diagnosed in 2009), hypertension, type II diabetes, and gouty arthropathy. The remainder of the Veteran’s private medical records likewise do not document any diagnosis of arthritis, past or present. The Board has no reason to doubt the competency or credibility of the Veteran’s private medical professionals and finds this evidence probative. The Board finds the lack of any documentation of a diagnosis of arthritis, past or present, indicates that the Veteran did not have arthritis because such an ailment would have been documented, just as his other ailments were documented. See Buczynski v. Shinseki, 24 Vet. App. 221, 226‒27 (2011) (where there is a lack of notation of medical condition or symptoms where such notation would normally be expected, the Board may consider this as evidence that the condition or symptoms did not exist). The Board has also considered the Veteran’s assertions of pain in relation to his claim for service connection for arthritis. The U.S. Court of Appeals for the Federal Circuit has held that pain alone may constitute a disability, even without an identifiable underlying pathology. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). The Veteran’s pain, however, must amount to a functional impairment to constitute a disability. Id. at 1367. “Functional impairment,” the Federal Circuit noted, is defined as the inability of the body or a constituent part of it “‘to function under the ordinary conditions of daily life including employment.’” Id. at 1363 (quoting 38 C.F.R. § 4.10). In other words, pain alone can qualify as a disability where it diminishes the body’s ability to function, even where it is not diagnosed as connected to a current underlying condition. Id. The Veteran testified that he used a cane to walk to and from his “transportation.” October 2020 Board Hearing Transcript, at 24. He did not provide any additional testimony or information about his limitations. Notably, his testimony was that after he had heart surgery in 2007, he was in great pain, which led him to retire. Id. at 27. The Board is unable to locate evidence that the Veteran’s pain, associated with his knees or another part of his body, in connection with his claim for arthritis, impacted his ability to function under ordinary conditions of daily life including employment. Therefore, the Board finds the Veteran’s pain, without more, does not constitute a disability for VA compensation purposes. Saunders, 886 F.3d at 1368. Finally, in the interest of completeness, the Board recognizes neither an examination nor medical opinion was obtained as to the Veteran’s claim for arthritis. The Board finds that VA was not under an obligation to provide one. Section 5103A of Title 38 of the United States Code, captioned “DUTY TO ASSIST,” mandates that a medical examination be provided in disability compensation claim cases only when: (1) There is competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability; (2) There is evidence establishing that an event, injury, or illness occurred in service or within an applicable presumptive period, or the Veteran has a service-connected disability; and (3) There is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) There is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); Waters v. Shinseki, 601 F.3d 1274, 1277 (Fed. Cir. 2010); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Each of the elements must be met. For the reasons previously discussed, the Board finds no competent evidence that the Veteran has or had during the pendency of his appeal a current disability of arthritis or pain causing functional limitation, nor does competent evidence demonstrate related persistent or recurrent symptoms. Therefore, the first element is not satisfied, which is dispositive. McLendon, 20 Vet. App. at 81; 38 U.S.C. § 5103A(d)(2)(A). Accordingly, a VA examination is not required in this case. In sum, the Board finds the competent, credible, and probative evidence of record weighs against finding that the Veteran has or had a current disability of arthritis during the pendency of his claim, which is a necessary element of both direct and secondary service connection. Accordingly, service connection is not warranted for the Veteran’s claim of arthritis. REASONS FOR REMAND During his October 2020 Board hearing, the Veteran identified two medical professionals who were treating his disabilities, Dr. G. and Dr. K. See October 2020 Board Hearing Transcript, at 13, 19. This was the first time the Veteran identified these medical professionals. Following the hearing, Dr. G. submitted a letter confirming that he was treating the Veteran for his cardiac conditions. Consistent with VA’s duty to assist, remand is warranted in order to attempt to obtain any relevant records from these medical professionals. 38 U.S.C. § 5103A(b). It is important to understand the Veteran’s arguments as to his remaining claims before addressing the reasons for remand. In his February 2016 notice of disagreement, he claimed only direct service connection for his heart condition(s) and diabetes mellitus, type II (diabetes). He claimed his hypertension was secondary only to his heart condition(s). He claimed his kidney disease and bilateral eye condition(s) were secondary only to his diabetes. He claimed only direct service connection for his gout but provided no argument or factual reasons for his claim. During his October 2020 Board hearing, he generally asserted that he believed his hypertension, kidney disease, bilateral eye condition, and gout were each secondary to his heart condition(s), diabetes, or both. The Board is required to consider theories of entitlement to benefits that are either raised by the claimant or reasonably raised by the record. Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008), aff’d sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). That obligation, however, “does not require the Board to assume the impossible task of inventing and rejecting every conceivable argument in order to produce a valid decision.” Robinson, 21 Vet. App. at 553. “Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory.” Robinson, 557 F.3d at 1361; see Shields v. Brown, 8 Vet. App. 346, 349‒50 (1995). The Board reasonably interprets the Veteran’s claims to be as follows: (1) As to his heart condition(s) and diabetes claims, they are claims for direct service connection only; (2) As to his hypertension claim, while he only claims secondary service connection with respect to his heart condition(s) and/or diabetes, the record reasonably raises a claim for direct service connection as well; and (3) As to his kidney disease, bilateral eye condition(s), and gout claims, he claims they are secondary to either his heart condition(s), diabetes, or both. The Board does not find reasonable evidentiary support or argument from the Veteran or the record to consider entitlement to service connection on a direct-basis theory for these claims. Robinson, 557 F.3d at 1361. 1. Entitlement to service connection for heart condition(s) (claimed as pericarditis and palpitations), to include as due to herbicide-agent exposure, is remanded. The Veteran has asserted two factual bases for his heart condition(s) claim: (1) exposure to diesel fuel/smoke while serving aboard the U.S.S. Tang (SS-563), a submarine, and (2) presumptive exposure to herbicide agents while serving aboard the vessel. The Veteran was afforded a VA examination in September 2015. “[O]nce the Secretary undertakes the effort to provide an examination when developing a service-connection claim, . . . he must provide an adequate one.” Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In this case, the opinion is inadequate for two reasons. First, the examiner opined that the Veteran’s current “chronic heart condition, [coronary artery disease]” was unlikely due to his history of pericarditis. The examiner provided no rationale to support her conclusion. Thus, her opinion carries no probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (“It is the fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion.”). There is no other competent, credible, and probative evidence (medical or lay) of record as to the etiology of the Veteran’s heart condition(s). Thus, a new VA examination is necessary. Second, the examiner did not have the benefit of considering the Veteran’s claim that he was exposed to diesel fuel/smoke while aboard the U.S.S. Tang as this was raised after the examination. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (opinion is adequate when it addresses the Veteran’s lay statements and medical history). As such, the Board finds it is appropriate to remand this matter for a new VA examination for consideration of this factual claim and adjudication by the RO in the first instance. In addition, after the case was certified to the Board, Congress enacted, and the President signed, the Blue Water Navy Vietnam Veterans Act of 2019 (Pub. L. No. 116-23, 133 Stat. 966) (the BWN Act), which extended presumptive herbicide-agent exposure to veterans of the Vietnam era who served within the 12-nautical-mile limit of Vietnam’s territorial sea, otherwise known as the “blue waters.” The Veteran asserts the U.S.S. Tang was within the territorial boundaries defined by the BWN Act during his active service. As the BWN Act had not yet come into existence when the RO adjudicated this case, the RO has not had the opportunity to develop whether the U.S.S. Tang served within 12 nautical miles of Vietnam’s shoreline. The Board notes the Veteran’s DD-214 indicates he was awarded the Vietnam Service Medal, which was only awarded to those military servicemen who, among other things, served in specified waters adjacent to Vietnam during the Vietnam era. See 32 C.F.R § 578.26(f) (2008) (defining the latitude and longitude boundaries), but see Decorations, Medals, Ribbons, and Similar Devices, 73 Fed. Reg. 66,754 (Nov. 12, 2008) (removing 32 C.F.R. Part 578 from publication). Importantly, these specified water boundaries partially overlap with the 12-nautical-mile boundary of the BWN Act. Furthermore, while the U.S.S. Tang is a submarine, the BWN Act was intended to cover “all vessels that served on or below the offshore waters of Vietnam,” including submarines. H. R. Rep. No. 116-58, at 11 (2019) (emphasis added). Therefore, consistent with VA’s duty to assist, 38 U.S.C. § 5103A, remand is also required in order to permit full development of the Veteran’s potential service within the 12 nautical miles off the shoreline of Vietnam consistent with the BWN Act and to determine whether he is entitled to presumptive herbicide-agent exposure and service connection. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). 2. Entitlement to service connection for diabetes mellitus, type II, to include as due to herbicide-agent exposure, is remanded. The Veteran has only reasonably identified one basis for service connection for his diabetes, which is as due to presumptive herbicide-agent exposure. Diabetes mellitus, type II, is a listed disease associated with exposure to herbicide agents. 38 C.F.R. § 3.309(e). As such, the Veteran may be entitled to presumptive service connection under 38 C.F.R. § 3.307(a)(6)(iii) in conjunction with the BWN Act if the U.S.S. Tang served within the 12-nautical-mile boundary off the shores of Vietnam during the Veteran’s active service aboard the vessel. Therefore, for the same reasons just discussed, remand is required as to the Veteran’s claim for service connection for diabetes to permit full development of his potential service within the 12 nautical miles off the shoreline of Vietnam. 38 U.S.C. §§ 1116, 5103A; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). 3. Entitlement to service connection for hypertension, to include as due to herbicide-agent exposure; and to include secondary to heart condition(s) and/or diabetes mellitus, type II, is remanded. Although not directly asserted by the Veteran, his general claim for service connection based on presumptive exposure to herbicide agents while serving aboard the U.S.S. Tang off the shores of Vietnam necessarily implicates his claim for service connection for hypertension. The Board finds the record reasonably raises this claim and will address it. Robinson, 557 F.3d 1355. While hypertension is not one of the presumptive conditions listed in 38 C.F.R. § 3.309(e) that are associated with exposure to herbicide agents, service connection may be established on a direct basis. Prior to 2018, the National Academy of Sciences (NAS) categorized the scientific evidence regarding an association between herbicide agents and hypertension as “limited or suggestive.” See 79 Fed. Reg. 20,308 (Apr. 11, 2014). Most recently, NAS upgraded its association determination between hypertension and herbicide-exposure from “limited or suggestive” to “sufficient,” indicating that “there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide-agent exposure. Veterans and Agent Orange: Update 11 (2018). Therefore, if the Veteran is entitled to presumptive exposure to herbicide agents, then he may be able to establish direct service connection for hypertension. Accordingly, the Board cannot make a fully informed decision until development of the Veteran’s potential exposure to herbicide agents is completed and an opinion is obtained that addresses the relationship between the Veteran’s hypertension and potential herbicide-agent exposure. Thus, remand is required. 4. Entitlement to service connection for kidney disease is remanded. 5. Entitlement to service connection for bilateral eye condition(s) (claimed as bilateral partial blindness) is remanded. 6. Entitlement to service connection for gout is remanded. As the dispositions for the remaining claims, 4 through 6, are the same, the Board will address them together. This discussion also pertains to the Veteran’s claim of secondary service connection for hypertension. The Veteran has asserted that his hypertension, kidney disease, bilateral eye condition(s), and gout are secondary to his heart condition(s), diabetes, or both. Yet, he is not currently service connected for either his heart condition(s) or diabetes. The second element for secondary service connection is that the Veteran have a current service-connected disability. 38 C.F.R. § 3.310 (b); Allen, 7 Vet. App. at 448. Consequently, the Board is unable to adjudicate the remaining claims because they are inextricably intertwined with his claims for service connection for heart condition(s) and diabetes. Roebuck v. Nicholson, 20 Vet. App. 307, 313 (2006) (claims are inextricably intertwined where they are “so closely connected that it is necessary that they be adjudicated together” because that could have a significant impact on each other). The Board finds it is necessary to remand the remaining claims for potential VA examinations and medical opinions depending on the outcome of the Veteran’s claims as to his heart condition(s) and diabetes. VA examinations and medical opinions on secondary service connection will only be necessary if either of the Veteran’s claims for his heart condition(s) or diabetes become service connected. See 38 C.F.R. § 3.159(c)(4). The Board points out that the Veteran has not asserted a reasonable factual basis or argument establishing that an event, injury, or illness occurred in service or within an applicable presumptive period in relation to his hypertension, kidney disease, bilateral eye condition(s), or gout, nor does the evidence or the Veteran’s arguments reasonably indicate these conditions may be attributable to some in-service event, injury, or disease. As such, the Board, at this time, finds no reasonable basis on which to afford him a VA examination on a theory of direct service connection on at this time. See 38 U.S.C. § 5103A(d); Waters, 601 F.3d at 1277; McLendon, 20 Vet. App. 79. Accordingly, the matters are REMANDED for the following actions: 1. Obtain any of the Veteran’s outstanding VA medical records and associate them with the claims file. 2. Send appropriate correspondence to the Veteran asking him to identify and authorize release of any relevant medical records from: (a.) Dr. H. G., M.D., from Salinas Valley Medical Clinic, as indicated during his October 2020 Board hearing testimony and the correspondence received by VA on October 22, 2020; (b.) Dr. K., as indicated during his October 2020 Board hearing testimony; and (c.) Any other relevant private treatment received for his heart condition(s), hypertension, diabetes, kidney disease, eye condition(s), and gout. 3. Submit appropriate requests to the appropriate agency, such as the Naval History and Heritage Command (NHHC), the National Archives Research Administration (NARA), the Joint Service Records Research Center Division (JSSRC), the United States Department of Defense, or any other appropriate source, requesting copies of deck logs and/or command histories for the U.S.S. Tang (SS-563), and any additional service personnel records, during the Veteran’s service period aboard the vessel, from 1965 to 1969, to attempt to verify whether the vessel was within the territorial waters of the Republic of Vietnam, to include within 12 nautical miles from the shoreline. With respect to any administrative finding as to whether the Veteran’s service aboard the U.S.S. Tang was within the 12-nautical-mile boundary of the Republic of Vietnam, the RO should consider the Veteran’s DD-214, and the criteria which resulted in the award of the Vietnam Service Medal 4. Only after directives 1, 2, and 3, are completed, obtain a new VA examination from a qualified clinician as to the onset and etiology of the Veteran’s claimed heart condition(s). The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide opinions on the following: (a.) Please identify what heart condition(s), if any, the Veteran (i) presently has and (ii) had during the pendency of his claim, from July 8, 2015 through the present, to include any residuals from the Veteran’s coronary artery bypass graft surgery in 2007. (b.) For each identified heart condition, whether it is at least as likely as not (50 percent probability or more) that the Veteran’s identified heart condition had its onset in or is otherwise etiologically related to an in-service event, injury, or disease, to include: (i) exposure to herbicide agents, presumptive or otherwise, and/or (ii) diesel fuel/smoke while serving aboard the U.S.S. Tang? (c.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s in-service complaints, diagnoses, and treatment for pericarditis, chest pains, angina, and dyspepsia caused or are at least reasonably medically related to his coronary artery bypass graft surgery in 2007? If so, whether it is at least as likely as not (50 percent probability or more) that any residuals of his 2007 heart surgery are etiologically related to his military service by consequence of his surgery being etiologically related to his military service? In rending his or her opinions, the examiner should consider and, if deemed relevant, address the following: (a.) The Veteran’s service treatment records: May 24, 1960 (diagnosis of pericarditis); January 10, 1977 (complaints of chest pain, diagnoses of angina or dyspepsia); March 16, 1977 (diagnosis of pericarditis); May 25, 1977 (complaints of chest pain); October 10, 1977 (exit examination that noted history of pericarditis with an “unknown etiology”). (b.) A September 2015 VA examination of the Veteran’s heart condition(s), which confirmed diagnoses of coronary artery disease and ischemic heart disease, but which did not consider the Veteran’s statements of exposure to diesel fuel/smoke. (c.) The Veteran’s lay statements and testimony that while aboard the U.S.S. Tang he was exposed to diesel fuel/smoke. Please refer to pages 5 through 7 of the October 2020 Board hearing transcripts. The examiner is reminded to consider the Veteran’s lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is competent to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran’s assertion of a heart condition(s) in service or the assertion that an in-service event, injury, or illness led to his heart condition(s). See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. If the examiner relies on medical treatises, the examiner must identify the treatises. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. 5. Only after directives 1, 2, and 3, are completed, and only if the RO determines that the evidence establishes the Veteran was exposed to herbicide agents in service, presumptively or otherwise, obtain a VA examination from a qualified clinician as to the onset and etiology of the Veteran’s hypertension. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion addressing: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s hypertension is due to exposure to herbicide agents, presumptively or otherwise. The examiner is reminded to consider the Veteran’s lay statements regarding the nature and onset of his disability, including any evidence concerning continuity of symptomatology, as he is competent to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran’s assertion of hypertension in service or the assertion that an in-service event, injury, or illness led to these disabilities. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. If the examiner relies on medical treatises, the examiner must identify the treatises. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. 6. Only after directives 1, 2, 3, 4, and 5 are completed, and only if the RO determines that either the Veteran’s heart condition(s), diabetes mellitus, type II, or both is/are service connected, obtain a VA examination from a qualified clinician as to the onset and etiology of the Veteran’s (a) hypertension, (b) kidney disease, (c) bilateral eye condition(s), and (d) gout. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. The examiner is asked to provide an opinion regarding: (a.) Whether it is at least as likely as not (50 percent probability or more) that the Veteran’s currently diagnosed i. hypertension; ii. kidney disease; iii. bilateral eye condition(s); and iv. gout were individually caused by (proximately due to or as the result of) his service-connected heart condition(s), diabetes mellitus, type II, or both. The examiner should provide individual opinions and rationales for each disability. (b.) Whether it is at least as likely as not (a 50 percent probability or more) that the Veteran’s currently diagnosed i. hypertension; ii. kidney disease; iii. bilateral eye condition; and iv. gout were individually aggravated by his service-connected heart condition(s), diabetes mellitus, type II, or both. The examiner is advised “aggravation” means an increase in the severity of the underlying disability beyond its natural progression. The examiner should provide individual opinions and rationales for each disability. The examiner is reminded to consider the Veteran’s lay statements regarding the nature and onset of his disabilities, including any evidence concerning continuity of symptomatology, as he is competent to report his symptoms, past medical history, and experiences. The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran’s assertion of a disability in service or the assertion that the Veteran’s service-connected disability led to his currently diagnosed hypertension, kidney disease, bilateral eye condition(s), or gout. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). A clear and detailed rationale for the opinion(s), including a discussion of the facts and medical principles involved, should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied. If the examiner relies on medical treatises, the examiner must identify the treatises. If a requested opinion cannot be provided without resorting to speculation, the examiner should so state and explain why an opinion cannot be provided without resorting to speculation. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. F. Sawka, 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.