Citation Nr: 21009546 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 12-14 471A DATE: February 22, 2021 ORDER A rating in excess of 10 percent prior to May 19, 2016 for lumbosacral strain is denied. A rating in excess of 20 percent from May 19, 2016 to November 24, 2019 for lumbosacral strain is denied. A 40 percent, but no higher, rating from November 25, 2019 for lumbosacral strain is granted, subject to regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for vision problems is remanded. Entitlement to service connection for joint pain in the bilateral wrists and bilateral hands is remanded. Entitlement to service connection for a stomach condition is remanded.   FINDINGS OF FACT 1. Prior to May 19, 2016, the Veteran’s lumbosacral strain resulted in a combined thoracolumbar range of motion of 230 degrees and in muscle spasm not resulting in an abnormal gait or spinal contour. 2. From May 19, 2016 to November 24, 2019, the Veteran’s lumbosacral strain resulted in forward flexion of the thoracolumbar spine of no less than 40 degrees. 3. From November 25, 2019, functional impairment from the Veteran’s lumbosacral strain, including during flare ups, resulted in impairment that more nearly approximated forward flexion limited to 30 degrees or less. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent prior to May 19, 2016 are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). 2. The criteria for a rating in excess of 20 percent from May 19, 2016 to November 24, 2019 are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). 3. The criteria for a 40 percent, but no higher rating from November 25, 2019 are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2006 to August 2007. He also had an earlier period of active duty for training from June 1994 to August 1994. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a March 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2018, the Veteran and his spouse testified at a videoconference hearing before the undersigned; a transcript of that hearing is of record. In May 2019, the Board remanded the Veteran’s appeal to the RO for further evidentiary development. Subsequently, a July 2020 rating decision granted service connection for a psychiatric disorder; gout impairing the flexion, supination, and pronation of the bilateral elbows; gout of the bilateral shoulders; gout of the left knee; hemorrhoids; and hypertension and an October 2020 rating decision granted service connection for trochanteric pain syndrome of the right and left hips. As these decisions constitute full grants of the benefits sought on appeal in regard to those disabilities, there remains no issue of controversy for adjudication by the Board on those claims. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Increased rating – Lumbosacral Strain The Veteran alleges that he is entitled to higher ratings for his lumbosacral strain disability. During the period on appeal to the Board, the Veteran has been assigned a 10 percent rating prior to May 19, 2016 and a 20 percent rating from that date under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. See 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. See 38 C.F.R. § 4.40. Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity, atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. See 38 C.F.R. § 4.45. Lumbar spine disabilities are rated using the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), unless the disability is rated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Rating Formula). 38 C.F.R. § 4.71a, Diagnostic Code 5237. The General Rating Formula provides that a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or muscle spasm, guarding, or localized tenderness not resulting in an abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted in cases of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range-of-motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is provided for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of the entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (5) states that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Under the IVDS Rating Formula, a 20 percent disability rating is assigned with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating is assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a maximum 60 percent disability rating is assigned with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician.  Prior to May 19, 2016 The Veteran underwent a VA examination for spine conditions in February 2010. The Veteran reported experiencing strong low back pain that he described as tightness and that worsened with prolonged standing and sitting. He also reported severe flare ups every 2 to 3 weeks that lasted hours that were precipitated by prolonged sitting, standing, and walking. He felt that he could not do any activity during flare ups. The Veteran reported having fatigue, decreased motion, stiffness, weakness, and muscle spasms. He indicated that his pain was moderate, occurred daily, and lasted for hours. He rated the pain as a 7 on a 10-pain scale. There were no incapacitating episodes. The Veteran did not have an abnormal spine curvature and although the Veteran had a muscle spasm of the spine, it did not result in an abnormal gait or abnormal spinal contour. Muscle strength, muscle tone, reflexes, and sensation to light touch in the lower extremities were normal. The Veteran reported numbness, paresthesias, and leg or foot weakness. The Veteran’s forward flexion was 0 to 80 degrees, extension 0 to 30 degrees, his right and left lateral flexion were each 0 to 30 degrees, and right and left lateral rotation were each 0 to 30 degrees. There was objective evidence of pain on range of motion testing and there were no additional limitations after three repetitions. The Veteran did not have a vertebral fracture, and the examiner diagnosed a lumbar strain. There was no bowel or bladder impairment noted. Private treatment records show that the Veteran was diagnosed with disc disease in October 2011. He reported lumbosacral pain in June 2012, November 2012, April 2013, and June 2015. In June 2012, the Veteran reported that his lumbosacral pain was radiating to his left leg. Based on a thorough review of the evidence for this period, the Board finds that the Veteran’s lumbosacral strain does not warrant a disability rating greater than 10 percent under the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. A rating of 20 percent or higher is warranted only if the forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, the combined range-of-motion of the thoracolumbar spine is not greater than 120 degrees; or, if the Veteran has muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Code 5237. The evidence of record does not demonstrate that the Veteran has exhibited forward flexion to 60 degrees or a combined range of motion of 120 degrees or less, or muscle spasm or guarding resulting in an abnormal gait or abnormal spinal contour during the appeal period. In evaluating the Veteran's increased rating claim, the Board must also address the provisions of 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 205 (1995). The Board recognizes the Veteran’s complaints of pain and functional loss as a result of his low back disability. Although functional loss is shown from the Veteran’s pain and limited motion as described, such is already contemplated in the assigned 10 percent rating, and the evidence does not more nearly approximate that consideration of such factors resulted in forward flexion greater than 30 degrees but not greater than 60 degrees or a combined range of motion not greater than 120 degrees. There also is no evidence of incapacitating episodes due to intervertebral disc syndrome; therefore, a rating in excess of 10 percent based on incapacitating episodes is not warranted. Regarding neurological impairment, the Veteran has been granted service connection for left lower extremity radiculopathy effective from November 23, 2011. Prior to that date, the preponderance of the lay and medical evidence of record is against a finding that the Veteran had any left lower extremity neurological impairment that would have warranted a separate rating. For the right lower extremity, the evidence prior to May 19, 2016 does not reflect any neurological impairment as muscle strength testing, sensation testing, and reflex testing were all normal on examination and there is no other indication of right lower extremity neurological impairment or radicular pain. Additionally, the evidence does not reflect that the Veteran had bowel or bladder impairment. Therefore, the weight of the evidence is against a finding that the Veteran is entitled to any other separate compensable ratings for neurological impairment. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent prior to May 19, 2016. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim is denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). From May 19, 2016 The Veteran underwent a VA examination in May 2016. The Veteran reported that he continued to have pain in the lumbar area during activities of daily living. He reported he did not have flare ups. He reported having functional impairment described as not being able to lift heavy objects. The examiner diagnosed a lumbosacral strain. The Veteran had forward flexion to 45 degrees. He showed pain on forward flexion. The Veteran was able to perform repetitive use testing and there was no additional loss of function or range of motion after three repetitions. There was pain on the palpation at the lumbar paravertebral muscles, and there was guarding or a muscle spasm not resulting in an abnormal gait or spinal contour. The Veteran’s muscle strength was normal and there was no muscle atrophy in the lower extremities. Reflex testing and sensation testing of the lower extremities were also normal. The examiner indicated the Veteran did not have radicular pain and did not have any other neurologic abnormalities, including bowel or bladder impairment. The Veteran did not have intervertebral disc syndrome. The Veteran did not use any assistive devices. The examiner indicated that the impact of the Veteran’s lumbar spine condition was that he could not do activities involving back twisting or extreme bending movements. He could not do heavy lifting, carrying, pushing, or pulling. He also could not do activities involving prolonged standing or prolonged ambulation. In his March 2018 hearing before the Board, the Veteran stated that he received treatment for his spine at the San Juan Veterans hospital and the treatment includes oral medication and injections which have been postponed due to his high blood pressure. The Veteran stated that his back condition makes it impossible to lift things. The Veteran’s wife stated that the Veteran was unable to sit for extended periods due to his back pain and that the condition continues to worsen. On November 25, 2019 VA examination, the Veteran’s forward flexion to 40 degrees with pain evidenced on movement but not resulting in functional loss. There was mild localized tenderness of the low back but no evidence of pain on weight-bearing. The range of motion did not change after three repetitions. The examiner indicated that pain significantly limited functional ability with repeated use over time and during flare ups but stated that he could not describe in range of motion terms. In that regard, the examiner indicated that the condition was aggravated by walking, prolonged sitting, and running, and the pain was alleviated by resting, limiting his activities, and medication. The Veteran was not having a flare up at the time of the examination, but reported that they occurred a few times a week, could last a week, and resulted in severe pain and severe limitation of his movement. He reported that he was unable to move during these episodes and would rest due to the pain. He also indicated that pain would limit activity such as walking, standing, and that he would have loss of range of motion. There was no guarding or muscle spasm. The Veteran’s muscle strength was normal, there was no muscle atrophy, and reflex and sensation testing were normal. The examiner noted radiculopathy in the left lower extremity. The Veteran did not have any other neurologic abnormalities, including bowel or bladder impairment. The Veteran did not have intervertebral disc syndrome. The Veteran occasionally used a back brace to help limit his mobility to avoid movement that could trigger pain. The examiner indicated that low back pain could limit walking and lifting. The Board finds that the Veteran is entitled to an increased 40 percent rating from November 25, 2019, the date of the VA examination that reflected the Veteran experienced severe flare ups that resulted in severely limited range of motion. Although the Veteran’s forward flexion was to 40 degrees on examination, the examiner noted that he experienced severe flare ups during which he was unable to move and had severe limitation of motion. He also indicated that the flare ups occurred a few times a week and could last up to a week. The examiner indicated he could not describe the functional impairment during flare ups based on range of motion. However, the Board concludes that the description of the flare ups places the evidence at least in equipoise that the Veteran’s forward flexion is limited to 30 degrees or less during flare ups that occur on a frequent basis. Therefore, the Board finds that the evidence more nearly approximates the criteria for a 40 percent rating from November 25, 2019. The weight of the evidence is against a finding that the Veteran is entitled to a higher 50 percent rating from November 25, 2019 as the evidence does not reflect findings that more nearly approximate unfavorable ankylosis. Although the Veteran indicated that his movement is severely limited during flare ups the evidence does not more nearly approximate that that the spine is fixed in flexion and includes one or more of the following symptoms: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Regarding the period from May 19, 2016 to November 24, 2019, the weight of the evidence is against a finding that the Veteran is entitled to a rating in excess of 20 percent. On May 2016 examination, forward flexion was to 45 degrees. Turning to the additional factors per 38 C.F.R. §§ 4.40 and 4.45, the Board finds that although the Veteran experienced pain and had functional loss with activities involving back twisting or extreme bending movements and could not do heavy lifting, carrying, pushing, or pulling or activities involving prolonged standing or prolonged ambulation, such functional impairment is considered in the 20 percent rating assigned during this time period. Although the Veteran reported experiencing increased symptoms at the March 2018 hearing, the symptoms described at that time were similar to those described at the May 2016 examination and did not more nearly approximate findings of forward flexion to 30 degrees or favorable ankylosis. Therefore, the date of the November 25, 2019 VA examination is the date it first became factually ascertainable that the Veteran experienced symptoms that more nearly approximated the criteria for a higher 40 percent rating. Regarding evaluation under the Formula for IVDS Based on Incapacitating Episodes, the Veteran does not have IVDS and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a rating in excess of 20 percent from May 19, 2016 to November 24, 2019 and in excess of 40 percent from November 25, 2019. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, as noted above, the Veteran has been granted service connection for left lower extremity radiculopathy and the rating for that condition is not before the Board. The preponderance of the lay and medical evidence of record is against a finding that the Veteran has experienced any right lower extremity neurological impairment that warrants a separate rating as the evidence reflects the Veteran did not experience radicular pain on the right side and muscle strength, reflex, and sensation testing on the right have all been normal from May 19, 2016. The preponderance of the lay and medical evidence of record is also against a finding that the Veteran has experienced any other neurological abnormality associated with his spine disability during this time. In summary, the Board finds that from May 19, 2016 to November 24, 2019, the preponderance of the evidence is against a rating in excess of 20 percent for the Veteran’s lumbar spine disability. From November 25, 2019, the Board concludes the evidence is at least in equipoise and resolves any doubt in the Veteran’s favor to conclude that the Veteran is entitled to a 40 percent, but no higher rating, for his lumbar spine disability. REASONS FOR REMAND 1. Entitlement to service connection for vision problems The Board’s May 2019 decision remanded the claim seeking service connection for vision problems to obtain a VA examination and opinion. On November 2019 VA examination, the optometrist diagnosed apparent toxoplasmosis of the right eye, dry eye syndrome bilaterally, simple astigmatism bilaterally, and presbyopia bilaterally. The Veteran reported that his dry eye and refractive error onset more than 10 years earlier. The examiner noted that the apparent toxoplasmosis was an incidental finding on the examination. The Veteran has used eyeglasses and eye lubricants as treatment. The Veteran reported experiencing blurred vision at far and near, burning sensation, red eyes and discomfort in both eyes. The November 2019 examiner opined that the dry eye condition was less likely than not related to computer use or dry air because dry eye is related to natural aging process producing an imbalance in the composition of tears. The examiner said that dry eye is common in persons over the age of 50. The examiner said that apparent toxoplasmosis is less likely than not caused by viewing computer monitors or by exposure to dry air because it is often caused by contact with cat droppings. Finally, the examiner noted that the Veteran’s simple astigmatism and presbyopia are both refractive errors. The Board finds the November 2019 opinion inadequate as it relates to the conditions of dry eye and toxoplasmosis as it appears to be based on an inaccurate factual premise. Regarding dry eye, the basis for the examiner’s opinion was that it was related to the natural aging process and that it is common in people aged 50 or more. However, at the time of the examination, the Veteran was younger than 50 and he indicated that he had been experiencing symptoms for more than 10 years, which would indicate onset was when he was 36 years old or younger. Therefore, a conclusion that dry eye was due to aging and was common in people aged 50 or more does not appear to take into consideration the particular facts associated with the Veteran’s case. Furthermore, regarding toxoplasmosis, the examiner only commented that toxoplasmosis could be acquired as a child if in contact with cat droppings in contaminated soil. However, the examiner did not indicate whether the Veteran had been exposed to cat droppings when he was a child. Therefore, the basis for this rationale is unclear and remand is necessary to obtain an adequate medical opinion that considers the particular facts of the Veteran’s case. 2. Entitlement to service connection for joint pain in the bilateral wrists and bilateral hands is remanded. In November 2019, the Veteran underwent VA examinations in which he was diagnosed with bilateral hand strains and bilateral wrist strains. The examiner opined that the hand and wrist strains were less likely than not caused by an exposure event in Southwest Asia. The examiner’s rationale was that hand and wrist strain can occur as a result of injury to tendons due to repetitive activity or trauma, and that there was no overwhelming evidence found suggesting that hand and wrist strain occurred as a result of an exposure event in Southwest Asia. At the March 2018 hearing, the Veteran testified that his occupational specialty in mortuary affairs required him to work between 18 and 20 hours a day managing up to five computers at a time. Although the November 2019 examiner indicated that repetitive activity could result in injury to tendons, the examiner did not address the nature of the Veteran’s military occupational specialty and the repetitive use of computers and typing as an in-service event. As such, remand is required in order to obtain an addendum opinion. 3. Entitlement to service connection for a stomach condition is remanded. The Veteran contends that he has a stomach condition which warrants service connection. On November 2019 VA examination, the examiner concluded that the Veteran’s stomach symptoms were an undiagnosed condition. Subsequent January 2020 VA treatment records reflect a diagnosis of gastritis and gastric ulcer. As a result of these diagnoses, the Agency of Original Jurisdiction requested an addendum opinion. In an August 2020 addendum opinion, the November 2019 VA examiner opined that gastritis and gastric ulcer were less likely than not related to the Veteran’s service, including service in Iraq, because “there was no evidence found in the [service treatment records] noting symptoms, diagnosis or treatment that may be related to gastric ulcer or gastritis such as heartburn, abdominal pain/epigastric pain associated with nausea and vomiting.” The Veteran’s service treatment records contain an August 2007 report of medical assessment in which the Veteran reported stomach pain. In his March 2018 testimony before the Board, the Veteran stated that while in Iraq he was treated for acid reflux and was prescribed omeprazole. Finally, during his November 2019 examination for stomach and duodenal conditions, the Veteran said that his stomach symptoms onset in 2006 when he was in Iraq, and resulted in abdominal pain, nausea, vomiting, and diarrhea. The examiner did not address the August 2007 report of stomach pain or the Veteran’s competent statements regarding the symptoms he experienced in service and after service. Therefore, a remand is necessary for a medical opinion which addresses this evidence. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s dry eye and apparent toxoplasmosis. An examination (including via telehealth) should only be obtained if the reviewing clinician determines one is necessary in order to provide the requested opinion. The examiner is asked to provide an opinion on the following question: Is it at least as likely as not that dry eye or apparent toxoplasmosis is related to an in-service injury, event, or disease, including watching computer monitors for extensive hours while on active duty or exposure to dry air while on active duty in Iraq? The examiner is asked to consider the Veteran’s competent lay statements regarding when he first began experiencing symptoms of dry eye and to consider the opinion from his spouse, an optometrist, provided at the March 2018 hearing, that dry eye is due to dry air in Iraq. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s bilateral hand and wrist strains. An examination (including via telehealth) should only be obtained if the reviewing clinician determines one is necessary in order to provide the requested opinion. The examiner is asked to provide an opinion on the following question: Is it at least as likely as not that the Veteran’s bilateral wrist strains and bilateral hand strains are caused by or onset during active duty service, to include from his duties as a mortuary affairs specialist? In providing this opinion, the clinician should consider the Veteran’s statements that his job as a mortuary affairs specialist required him to manage up to 5 computers at a time for 18 to 20-hour shifts. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 3. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s stomach condition. An examination (including via telehealth) should only be obtained if the reviewing clinician determines one is necessary in order to provide the requested opinion. The examiner is asked to provide an opinion on the following question: Is it at least as likely as not that the Veteran’s gastritis and gastric ulcer are caused by or onset during active duty service? The clinician should consider and address lay evidence including an August 2007 report of medical assessment in which the Veteran reported stomach pain; a March 2009 letter from the Veteran to VA indicating that he had a stomach condition; the Veteran’s March 2018 testimony to the Board that while in Iraq he was treated for acid reflux and was prescribed omeprazole; and his statement during the November 2019 examination for stomach and duodenal conditions that his stomach symptoms onset in 2006 when he was in Iraq, and resulted in abdominal pain, nausea, vomiting, and diarrhea. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Dean 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.