Citation Nr: 21009426 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 15-13 041 DATE: February 22, 2021 ORDER Service connection for a psychiatric disorder, diagnosed as a depressive disorder, not otherwise specified, is granted. REMANDED Entitlement to service connection for a right elbow disability is remanded. Entitlement to service connection for a left elbow disability is remanded. Entitlement to service connection for a dental disability for compensation purposes is remanded. Entitlement to an initial higher (compensable) rating for bilateral hearing loss is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT The Veteran’s psychiatric disorder, diagnosed as a depressive disorder, not otherwise specified, had its onset in service. CONCLUSION OF LAW The criteria for service connection for a psychiatric disorder, diagnosed as a depressive disorder, not otherwise specified, have been met. 38 U.S.C. §§ 101(24),1101, 1110, 1112, 1113, 1117, 1131, 1137, 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the Army from May 1978 to May 1981, and from February 2003 to August 2003, including service in the Southwest Asia Theater of Operations. He also had many years of additional service in the Puerto Rico Army National Guard. This matter is before the Board of Veterans’ Appeals (Board) on appeal of an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico, that granted service connection and a noncompensable rating for left ear hearing loss, effective September 12, 2012. By this decision, the RO also denied service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD) (listed as PTSD). As there are multiple other psychiatric diagnoses of record, the Board finds that it is more appropriate to characterize the claim broadly as one of entitlement to service connection for a psychiatric disorder, to include PTSD. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The RO further denied service connection for a right elbow disability; a left elbow disability; right ear hearing loss; and for a dental disability. The Board notes that a claim of service connection for a dental disability is also a claim for VA outpatient dental treatment under 38 C.F.R. § 3.381. Mays v. Brown, 5 Vet. App. 302 (1993). In dental claims, the RO adjudicates the claim of service connection for compensation benefits and the VA Medical Center (VAMC) adjudicates the claim for outpatient treatment. As this matter stems from an adverse determination by the RO, the appeal is limited to the issue of service connection for a dental disability for the purpose of compensation. The claim of service connection for a dental disorder for the purpose of obtaining VA outpatient dental treatment is referred to the RO, for additional referral to the appropriate VAMC. See 38 C.F.R. § 17.161. In June 2019, the Board remanded the issues of entitlement to service connection for a psychiatric disorder, to include PTSD; a right elbow disability; a left elbow disability; right ear hearing loss; and a dental disability for compensation purposes, as well as the issue of entitlement to an initial higher (compensable) rating for left ear hearing loss, for further development. A March 2020 RO decision granted service connection for right ear hearing loss, effective February 23, 2016. The RO also continued a noncompensable rating for bilateral hearing loss. Therefore, the issue of entitlement to service connection for right ear hearing loss is no longer on appeal. Psychiatric Disorder, to include PTSD Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). The term “active military, naval, or air service” includes active duty, any period of active duty for training during which the individual was disabled or died from a disease or injury incurred in or aggravated in the line of duty, and any period of inactive duty training during which the individual was disabled or died from an injury incurred in or aggravated in the line of duty. 38 U.S.C. § 101 (24). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical and lay evidence, with due consideration to VA’s policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310 (2015); see also Allen v. Brown, 7 Vet. App. 439 (1995). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., under the criteria of DSM-IV); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. If the evidence establishes that the veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f). Further, 38 C.F.R. § 3.304(f) provides that if a stressor claimed by a Veteran is related to the Veteran’s fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of [PTSD] and that the Veteran’s symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the Veteran’s service, the Veteran’s lay testimony alone may establish the occurrence of the claimed in-service stressor. The Veteran served in the Southwest Asia Theater of Operations during the Persian Gulf War, on or after August 2, 1990. 38 U.S.C. § 1110. Therefore, service connection may also be established under 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Under those provisions, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia Theater of Operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1). Under 38 C.F.R. § 3.317, compensation may be warranted on a presumptive basis for disabilities due to undiagnosed illness as well as medically unexplained chronic multisymptom illnesses. See 38 C.F.R. § 3.317 (a). This means that even if a Veteran’s symptoms are attributed to a known clinical diagnosis, the presumptive provisions related to Gulf War service still apply. In particular, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(ii). Therefore, even if a multisymptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multisymptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board”). The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran’s demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The Veteran contends that he has psychiatric disorder, to include PTSD, that is related to service. He specifically maintains that he served a combat tour with Operation Noble Eagle. The Veteran reports that he was exposed to daily explosions, and that he was involved in ambushes and fast action flanking objectives for tankers. He states that he felt sad when a fellow soldier never returned after his mission. The Veteran indicates that he was discharged mainly because his nervous condition worsened over his twenty years of service. The Veteran essentially asserts that his psychiatric disorder, to include PTSD, began during his periods of service. The Veteran served on active duty in the Army from May 1978 to May 1981, and from February 2003 to August 2003, including service in the Southwest Asia Theater of Operations. He also had many years of additional service in the Puerto Rico Army National Guard. The Veteran’s DD Form 2014, for his period of active duty from May 1978 to May 1981, lists his occupational specialty as a Hercules missile carrier member for two years and eight months. His DD Form 2014, for his period of active duty from February 2003 to August 2003, lists his occupational specialty as an infantryman for six months, that he was ordered to active duty in support of Operation Noble Eagle, and that he served in Kuwait from March 2003 to June 2003. The Veteran service treatment records for his period of active duty from May 1978 to May 1981 show that he was treated for possible psychiatric problems. A June 1978 treatment entry notes that the Veteran was transported by an ambulance service, with a chief complaint of syncope. The examiner reported that the Veteran had anxiety after seeing a film on heat injuries. It was noted that the Veteran reported that he had shortness of breath, pain, and oral numbness, as well as tightness in his fingers and toes. The assessment was hyperventilation. Another June 1978 treatment entry, the next day, indicates that the Veteran complained of hyperventilation and passing out twice, two days earlier, with loss of consciousness for two to three minutes. The Veteran also stated that he had two nose bleeds. The assessment was past hyperventilation. A February 1979 entry notes that the Veteran complained of chest pain when the mornings arrived. The examiner reported that the Veteran was hyperventilating, and that he had a history of emotional problems. It was noted that the Veteran would be referred to a medical clinic. A February 1979 hospital report notes that the Veteran complained of chest pain, and that he had a history of emotional problems. The examiner reported that the Veteran hyperventilated for thirty minutes, and that his behavior was apprehensive. The diagnosis was hyperventilation. An April 1979 treatment entry indicates that the Veteran reported that he was doing better. It was noted that a chest x-ray was possibly not performed, and that an echocardiogram was not performed. The assessment was non-cardiac chest pain. A February 1981 treatment entry reflects that the Veteran was seen for ear pain for eight days. It was noted that the Veteran also reported that he had not been sleeping at night. The impression was otitis externa and otitis media. The Veteran’s service treatment records for his period of active duty from February 2003 to August 2003 do not specifically show treatment for any psychiatric problems. Post-service private and VA treatment records, including a VA examination report, show treatment for variously diagnosed psychiatric disorders, including an adjustment disorder, with mixed anxiety and a depressed mood; an adjustment disorder, with mixed anxiety and depression; PTSD; depression-anxiety; a major depressive disorder, recurrent, severe, without psychotic features; and a depressive disorder, not otherwise specified. An October 2013 VA psychiatric examination report includes a notation that the Veteran’s claims file was reviewed. The Veteran reported that he was in the military from May 1978 to May 1981, and that he was in the Army Reserve from 1987 to 1997. He stated that he deployed from June 2002 to July 2002, and from February 2003 to August 2003, during Operation Enduring Freedom. The Veteran stated that he also had service in the National Guard. He indicated that he dealt with the sound of daily explosions during his periods of service. The Veteran also reported that he felt sad when he heard that a fellow soldier never returned back after a mission. It was noted that no disciplinary difficulties were reported, and that there was no documented active combat or injuries. The diagnosis was a depressive disorder, not otherwise specified. The examiner indicated that the claimed condition was less likely than not (less than 50 percent probability) incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner reported that there was no evidence of psychiatric complaints, findings, or treatment prior to the Veteran’s military service. The examiner stated that there was also no evidence of psychiatric complaints, findings, or treatment during the Veteran’s military service. It was noted that there was no evidence of psychiatric complaints, findings, or treatment within one year after the Veteran’s discharge from his military service. The examiner indicated that the Veteran sought psychiatric treatment in 2012. The examiner maintained that although an established diagnosis of PTSD was documented in a psychiatric evaluation dated in March 2012, there was no medical evidence to meet the criteria for PTSD was documented in the evaluation. The Board observes that the Veteran’s service treatment for his period of active duty from May 1978 to May 1981 show that he was treated for possible psychiatric problems, and that he was specifically noted to have symptoms such as anxiety after seeing a film about heat injuries; emotional problems; and that his behavior was apprehensive. The Veteran was diagnosed with hyperventilation and non-cardiac chest pain. His service treatment records for his period of active duty from February 2003 to August 2003 do not specifically show treatment for psychiatric disorders. The Board notes that post-service private and VA treatment records, including a VA examination report, show treatment for variously diagnosed psychiatric disorders, including an adjustment disorder, with mixed anxiety and a depressed mood; an adjustment disorder, with mixed anxiety and depression; PTSD; depression-anxiety; a major depressive disorder, recurrent, severe, without psychotic features; and a depressive disorder, not otherwise specified. The Board notes that an October 2013 VA psychiatric examination report relates a diagnosis of a depressive disorder, not otherwise specified. The examiner, following a review of the claims file, indicated that the claimed condition was less likely than not incurred in, or caused by, the claimed in-service injury, event, or illness. The examiner stated that there was no evidence of psychiatric complaints, findings, or treatment during the Veteran’s military service, or within one year after the Veteran’s discharge from his military service. The examiner also indicated that the Veteran sought psychiatric treatment in 2012. The examiner maintained that although an established diagnosis of PTSD was documented in a psychiatric evaluation dated in March 2012, there was no medical evidence to meet the criteria for PTSD was documented in the evaluation. The Board observes that the examiner specifically stated that there was no evidence of psychiatric complaints, findings, or treatment during the Veteran’s periods of military service. The Board notes, however, as discussed above, that the Veteran’s service treatment records, for his period of active duty from May 1978 to May 1981, show that he was noted to have symptoms such as anxiety after seeing a film about heat injuries; emotional problems; and that his behavior was apprehensive. Additionally, the examiner did not specifically address the Veteran’s reports of psychiatric problems since his periods of service. The Board observes that the Veteran is competent to report that he had psychiatric problems since his periods of service. See Davidson, 581 F.3d at 1313. Therefore, the Board finds that the negative opinions by the examiner, pursuant to the October 2013 VA psychiatric examination report, have little probative value in this matter. The Board observes that the medical evidence indicates that the Veteran currently has a psychiatric disorder, diagnosed as a depressive disorder, not otherwise specified. Additionally, the Board notes that the Veteran is competent to report symptoms of his psychiatric disorder, diagnosed as a depressive disorder, not otherwise specified, during service and since that time. Moreover, the Board finds that the Veteran’s reports of such symptoms are credible. See Jandreau v. Nicholson, 492 F.3d 1372 (2007). Resolving any doubt in the Veteran’s favor, the Board finds that the evidence is at least in equipoise regarding whether the current psychiatric disorder, diagnosed as a depressive disorder, not otherwise specified, commenced during his periods of service. In light of the evidence of record, the Board cannot conclude that the preponderance of the evidence is against granting service connection for a psychiatric disorder, diagnosed as a depressive disorder, not otherwise specified. Accordingly, service connection for a psychiatric disorder, diagnosed as a depressive disorder, not otherwise specified, is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; See also Clemons v. Shinseki, 23 Vet. App. 1 (2009). REASONS FOR REMAND The remaining issues on appeal are entitlement to service connection for a right elbow disability; a left elbow disability; and for a dental disability for compensation purposes, as well as entitlement to an initial higher (compensable) rating for bilateral hearing loss and entitlement to a TDIU. The Veteran contends that he has a right elbow disability; a left elbow disability; and a dental disability for compensation purposes, that are related to service. He also asserts that his claimed disabilities are the result of his service in Southwest Asia and should be considered under the provisions of 38 C.F.R. § 3.317. The Veteran further reports that his claimed dental disability for compensation purposes occurred as a result of an Anthrax vaccine. The Veteran served on active duty in the Army from May 1978 to May 1981, and from February 2003 to August 2003, including service in the Southwest Asia Theater of Operations. He also had many years of additional service in the Puerto Rico Army National Guard. The Veteran’s service treatment records for his first period of service from May 1978 to May 1981 show that he was treated for a right elbow problem on one occasion. Such records do not specifically show treatment for left elbow problems or for a dental disability. A May 1980 treatment entry notes that the Veteran complained of right elbow pain for three to four months. He stated that the pain began as a small ache and that it was gradually worsening. The assessment was post-trauma effusion. The Veteran’s service treatment records for his active duty from February 2003 to August 2003 do not specifically show treatment for any right elbow problems and/or left elbow problems. Such records do refer to treatment for possible dental problems. A July 2003 report of medical assessment, at the time of a post-deployment assessment, notes that the Veteran reported, as to dental problems, that he had loose teeth. The reviewing examiner indicated that the Veteran was not referred for further evaluation. A January 2006 initial medical review report, for National Guard purposes, notes that the Veteran reported that he had been seen by, or treated by, a dentist, physician, or other health care provider since his last periodic physical examination. The Veteran indicated that he was treated for loose teeth. The Board observes that the Veteran has not been afforded a VA examination, as to his claimed right elbow disability; left elbow disability; and dental disability for compensation purposes. Therefore, the Board finds that the Veteran has not been afforded a VA examination, with the opportunity to obtain responsive etiological opinions, following a thorough review of the entire claims file, as to his claims for service connection for a right elbow disability; a left elbow disability; and for a dental disability for compensation purposes. Such an examination must be accomplished on remand. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). As to the Veteran’s claim for a higher rating for bilateral hearing loss, the Board notes that the Veteran was last afforded a VA audiological examination in February 2016. The diagnoses were sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, in the right ear, and sensorineural hearing loss, in the frequency range of 500 to 4000 Hertz, in the left ear. Since that time, in a January 2021 informal hearing presentation, the Veteran’s representative appeared to indicate that the Veteran’s hearing had worsened. As such, the Board finds it necessary to remand this matter to afford him an opportunity to undergo a contemporaneous VA examination. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). Further, the Board notes that a request for a TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when a TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits of the underlying disability. Id at 454. The Board finds that the record raises the issue of a TDIU in this matter. In light of Rice and the remand of the claims service connection, and for a higher rating for bilateral hearing loss, the TDIU issue must be remanded because the claims are inextricably intertwined and must be considered together. Thus, a decision by the Board on the Veteran’s TDIU rating claim would, at this point, be premature. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009). Additionally, the Board finds that a remand is required to request that the Veteran complete a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, or in order for the Veteran to provide the information requested on such form. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all medical providers who have treated him for right elbow problems; left elbow problems; dental problems; and bilateral hearing loss, since March 2020. After receiving this information and any necessary releases, obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain the records, inform the Veteran of such, and advise him that he may obtain and submit those records himself. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service symptoms of his claimed right elbow disability; left elbow disability; and dental disability for compensation purposes, as well as the nature, extent, and severity of his service-connected bilateral hearing loss and the impact of that condition on his ability to work. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Request that the Veteran provide a completed VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, or a comparable statement as to the information requested on such form. 4. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to determine the nature and likely etiology of his claimed right elbow disability; left elbow disability; and dental disability for compensation purposes. The claims file must be reviewed by the examiner. Based on the results of the examination, the examiner is asked to address each of the following questions: (a) Please state whether the symptoms of each claimed condition are attributable to a known clinical diagnosis. If the Veteran does not now have, but previously had any such condition, when did that condition resolve? (b) Is the Veteran’s disability pattern consistent with: (1) a diagnosable but medically unexplained chronic multisymptom illness of unknown etiology, (2) a diagnosable chronic multisymptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis? (c) If, after examining the Veteran and reviewing the claims file, it is determined that the Veteran’s disability pattern is either (1) a diagnosable chronic multisymptom illness with a partially explained etiology, or (2) a disease with a clear and specific etiology and diagnosis, then please provide an expert opinion as to whether it is related to a presumed environmental exposures experienced by the Veteran during service in Southwest Asia. (d) Is it at least as likely as not that any diagnosed disorder had its onset directly during the Veteran’s service or is otherwise causally related to any event or circumstance of his service, including environmental exposures during service in Southwest Asia during the Persian Gulf War? (e) If not directly related to service on the basis of questions (b)-(d), is any medical condition proximately due to, the result of, or caused by any service-connected disability(ies)? (f) If not caused by another medical condition, has any disorder been aggravated by any service-connected disability(ies)? If yes, was that increase in severity due to the natural progress of the disease. In responding to the above inquiries, please acknowledge and discuss the Veteran’s treatment during his first period of active duty from May 1978 to May 1981 for a right elbow problem, and his report during his second period of active duty from February 2003 to August 2003 that he had loose teeth, as well as any reports of the Veteran of treatment for his claimed disabilities during and since his periods of service. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. D. Regan, 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.