Citation Nr: 21011734 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 17-31 840 DATE: March 2, 2021 ORDER Entitlement to service connection for a muscle disability, to include as due to an undiagnosed illness is denied. REMANDED Entitlement to service connection for a sleep disability, to include as due to an undiagnosed illness is remanded. Entitlement to service connection for a lung disability, to include as due to an undiagnosed illness is remanded. FINDING OF FACT The Veteran’s claimed muscle disability did not begin during active service, and is not otherwise related to an in-service injury, event, or disease; there is no current diagnosis of a muscle disability and his current symptoms have been competently attributed to a known diagnosis. CONCLUSION OF LAW The criteria for service connection for a muscle disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active military service with the US Navy from May 1989 to May 1993. These matters come to the Board of Veteran’s Appeals (Board) following a September 2019 remand. The claims are on appeal from a January 2017 rating decision from the Department of Veterans Affairs (VA) regional office (RO) in Lincoln, Nebraska. In May 2019, the Veteran presented testimony before the undersigned Veterans Law Judge at a travel Board hearing. A copy of this transcript has been associated with the claims file. The Veteran is seeking service connection through either direct service connection, service connection due to chronicity, or service connection through the undiagnosed Gulf War illness presumption. Direct service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303 (a) (2016). Establishing direct service connection generally requires competent evidence of (1) a current disability; (2) 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. Shedden v. Principi, 381 F.3d 1163, 1167(Fed. Cir. 2004). Service connection through chronicity may be identified with reference to other VA regulations. Chronic diseases in general are enumerated “chronic disease” listed under 38 C.F.R. § 3.309 (a). Establishing chronic disease in this way requires a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331(Fed. Cir. 2013). Service connection may also be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from undiagnosed illness that became manifest either during active 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, 2016, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117 ; 38 C.F.R. § 3.317 (a)(1) (VA has issued an interim final rule extending this date to December 31, 2016). In claims based on undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. Id. A “qualifying chronic disability” for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome (CFS), fibromyalgia, or irritable bowel syndrome) that is defined by a cluster of signs or symptoms, or (C), any diagnosed illness that the VA Secretary determines in regulation prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service connection. 38 U.S.C. § 1117 (a)(2); 38 C.F.R. § 3.317 (a)(2)(i)(B). To establish the undiagnosed Persian Gulf War illness presumption, “objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to a physician, and other, non-medical indicators that are capable of independent verification. To fulfill the requirement of chronicity, the illness must have persisted for a period of six months. 38 C.F.R. § 3.317 (a)(2),(3). Signs or symptoms that may be manifestations of undiagnosed illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). The Veteran is a Persian Gulf Veteran. The term “Persian Gulf Veteran” means a Veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317 (d)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. See 38 U.S.C. § 1117 ; 38 C.F.R. § 3.317 (d)(2). The Persian Gulf War period runs from August 2, 1990 to a date not later than December 31, 2016. 38 U.S.C. § 101 (33). 1. Entitlement to service connection for a muscle disability, to include as due to an undiagnosed illness The Veteran contends that he has a muscle disability that is related to his active service; specifically, he has asserted that he experiences ongoing muscle pain as a result of his duties on an aircraft carrier or alternatively, as due to environmental hazards during his active service in the Persian Gulf. The service treatment records (STR’s) reflect that the Veteran’s May 1989 enlistment exam, “pertinent data” section does not mention any muscle related symptoms or treatments, and the enlistment exam “defects” summary and “significant interval history” sections are blank. Likewise, The Veteran’s March 1993 separation exam does not mention any muscle pain related symptoms or treatment. In January 2017, medical records associated with the claims file reflect that the Veteran was diagnosed with lumbar spondylosis. In January 2017, the RO denied the Veterans service connection claim for muscle pain as due to an undiagnosed illness on the basis that there was no in-service event and the Veteran has a known clinical diagnosis. In March 2017, the Veteran’s wife submitted a statement indicating that the Veteran suffers from muscle pain in his back and his legs. She reported that he frequently uses over the counter pain relief medication in order to be able to get through his working day. Also, in March 2017, the Veteran submitted a notice of disagreement (NOD) and indicated that he has had muscle pain since the time that he left service. In May 2017 the RO denied the Veteran’s service connection claim for muscle pain as due to an undiagnosed illness in the basis that the 2016 medical examiner identified degenerative arthritis of the spine and patellofemoral pain syndrome and arthritis of the knees, which constitute known clinical diagnoses. In June 2017, the Veterans submitted an Appeal on a Form 9, including a statement indicating that he was exposed to many environmental hazards during his tour of duty in Southwest Asia and that before he entered military service, he did not have any muscle aches or pains. The Veteran requested reconsideration of service connection for muscle pain as due to an undiagnosed illness. The Veteran offered additional evidence when he testified at a May 2019 Board hearing. The Veteran and his representative notified the Board of additional outstanding private medical treatment records for his back pain, which were subsequently obtained and associated with the Veteran’s file. In September 2019, the Board remanded the Veteran’s claims to determine the nature and etiology of the Veteran’s claimed muscle disability and also to provide a medical nexus opinion as to whether the claimed condition is directly related to the Veteran’s active service. See May 2019 Board hearing transcript. Pursuant to the September 2019 Board remand, the Veteran was afforded a VA medical examination on January 20, 2020. The medical examiner was asked to opine whether the medical records support that any currently diagnosed conditions claimed as muscle disability were incurred in or caused by working on an aircraft carrier or alternatively as due to environmental hazards during the Veteran’s active service in the Persian Gulf. The examiner responded that while the Veteran does have a history of lumbar strain from 2001, medical records show that with physical therapy, the muscular pain from that strain resolved. When questioned about potential other muscle disabilities the Veteran voiced to the medical examiner that he was mainly concerned with his back. A radiograph of the Veteran’s lumbar spine dated December 2016 showed degenerative disc disease, which is a bony condition rather than a muscle condition. The examiner found that in the absence of medical evidence to support a muscle diagnosis, the claimed muscle disability is less likely than not incurred in or caused by the Veteran’s work on aircraft carriers or environmental exposures. Further, the examiner opined that the Veteran’s reported current civilian occupation was physically demanding. The Veteran was responsible for carrying and assembling furniture. The examiner opined that the Veteran’s intermittent muscle spasms may occur as a consequence of the Veteran’s current civilian occupation. VA treatment records dated May 2012 to July 2020 are consistent with the reports in the VA medical examination opinions. With regard to the Persian Gulf War undiagnosed illness claim, the Veteran is not required to provide competent evidence linking a current disability to an event during service. Gutierrez v. Principi, 19 Vet. App. 1 (2004). As applied to the Veteran’s claim herein, to the extent that the Veteran is claiming entitlement to VA compensation for muscle pain due to undiagnosed illness, this aspect of his claim is denied as his muscle pain is attributable to a clear and specific current medical diagnosis of degenerative arthritis of the spine and patellofemoral pain syndrome and arthritis of the knees (December 2016 VA Gulf War medical examiner) and a December 2016 radiograph of the spine showed degenerative disc disease. Therefore, as no undiagnosed illness is demonstrated as the cause of the Veteran’s muscle pain symptoms, he does not meet the criteria for service connection pursuant to 38 C.F.R. § 3.317. Establishing direct service connection can be accomplished if there is a current diagnosis and proof of actual direct causation with an in-service disease or injury. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The determination of whether the requirements of service connection have been met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181(1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Barr v. Nicholson, 21 Vet. App. 303 (2007). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3. A claimant need only demonstrate an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For a claim to be denied on the merits, a preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1131; Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). With regard to direct service connection, after considering all of the evidence, the Board concludes that the Veteran does not have a current diagnosis of a muscle disorder and on that basis the claim must be denied. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). In reaching the above conclusion, the Board has not overlooked the Veteran’s statements and those of his wife in support of his claim. While the Veteran believes that he incurred a muscle disorder during service, the January 2020 examiner found that in the absence of medical evidence to support a diagnosis, the claimed muscle disability is less likely than not incurred in or caused by the Veteran’s work on aircraft carriers or environmental exposures during his time in service. The Veteran was not treated during service or shortly thereafter for any similar symptoms and further, the Veteran’s reported physically demanding current civilian occupation (at the time of the examination), carrying and assembling furniture, could be responsible for causing the Veteran’s reported symptoms. As a layperson, the diagnosis and etiology of a muscle disorder diagnosis are matters not capable of lay observation and require medical expertise to determine. Accordingly, the Veteran’s opinion as to the diagnosis or etiology of his claimed muscle disorder does not constitute competent medical evidence. As the weight of the evidence of record does not demonstrate that the Veteran suffers from a current diagnosis of any service related muscle pain disorder, or from any undiagnosed illness pursuant to the Gulf War presumption, the Board must deny the claim on appeal for entitlement to service connection for muscle pain. REASONS FOR REMAND 1. Entitlement to service connection for a sleep disability, to include as due to an undiagnosed illness is remanded. The Veteran contends he suffers from a sleep disability that is related to his active service. Specifically, he maintains that he has problems falling and staying asleep as a result of shift work during his active service or alternatively, as due to environmental hazards during his active service in the Persian Gulf. The Veteran’s STRs reflect that the Veteran’s May 1989 enlistment exam, “pertinent data” section does not mention any sleep disorder related symptoms or treatments, and the enlistment exam “defects” summary and “significant interval history” sections are blank. Likewise, The Veteran’s March 1993 separation exam does not mention any sleep related symptoms or treatment. With regard to the Persian Gulf War undiagnosed illness claim, the Veteran underwent a December 2016 VA Gulf War general medical examination. The examiner opined that the Veteran’s claimed sleep condition was less likely than not related to Gulf War illness or due to an exposure event in Southwest Asia, but instead was a disease with a clear and specific etiology. The examiner opined that the Veteran’s December 2016 VA obstructive sleep apnea examination reflected no diagnosis of any specific sleep condition; instead the Veteran was “advised to have a mental health examination for what appeared to be ‘classic’ insomnia.” Other reports and evidence with regard to the Veteran’s claimed sleep disorder are as follows. In September 2019, the Board noted that both the Veteran and his spouse submitted multiple lay statements regarding his ongoing sleep-related symptoms; further, the Veteran also submitted new medical treatment records with documentation of his sleep symptoms. In light of the newly submitted medical evidence, the Board remanded for an examination. Other consistent evidence was received when the Veteran testified at a May 2019 Board hearing. In order to evaluate the claims for service connection of a sleep disorder, the Veteran was afforded an initial examination for a mental health disorder January 22, 2020. The December 2016 examiner had advised that the appropriate examination would be with a qualified mental health evaluator. At the January 22, 2020 mental health examination conducted by SG, PsyD, the Veteran reported that sleep apnea was diagnosed July 2019. He was prescribed a CPAP machine but at the time of the 2020 examination he reported that he was not using it. The Veteran denied that any sleep related symptoms impact his occupation. The Veteran stated he commuted to work for about an hour and therefore he has time to wake up and feel awake in order to do his job. The January 22, 2020 mental health disorder examiner continued by noting that the Veteran reported sleep disturbances began in service while working on the flight deck. He stated that it became difficult for him to fall asleep and stay asleep during the night, without understanding the cause. He reported that since his time in the Navy his eyes will be closed and he will “think [he] is asleep but [his] ears don’t shut down.” The Veteran reported difficulty falling asleep and then waking throughout the night. He said that he became accustomed to the noise on the ship and reported he now requires white noise in order to fall asleep. The Veteran denied mental health treatment or medications in the military. The examiner noted that on the Veteran’s separation examination in March 1993, the Veteran responded “NO” to the question “Frequent trouble sleeping.” The examiner, SG, PsyD, Psychologist, concluded that the Veteran does not now suffer from, nor has he ever been diagnosed with a mental disorder. January 22, 2020 Mental Health Disability Questionnaire DBQ. Also, on January 22, 2020, the Veteran was evaluated for a medical opinion (as distinguished from the mental health evaluation discussed above) pursuant to a claimed sleep disability by the same practitioner who completed the mental health examination: SG, PsyD, Psychologist. See Medical Opinion DBQ, January 22, 2020. The examiner expressed internally inconsistent opinions and accordingly another evaluation is needed. The medical opinion DBQ addresses both direct service connection requirements and Gulf War presumption requisites. Initially, the examiner responded with a negative opinion on both of these issues, Page 2, Section II; Page 2, Section III. After reporting a negative opinion, the examiner then reported that they are not qualified to render an opinion, because an undiagnosed medical illness would be more appropriately addressed by a provider with different credentials. Page 5, Add. Question 1. A. With regard to direct service connection, the examiner changed from a negative to a positive service connection opinion. At Page 5, Add. Question 2B the examiner stated at that there is a positive likelihood that the Veteran’s sleep disturbance began during or is otherwise related to the Veteran’s active duty service, although previously the examiner answered the question in the negative. The opinion is accordingly not adequate for purposes of evaluating the Veteran’s claims. Although the Board sincerely regrets the further delay, another remand is required with regard to the Veteran’s sleep disorder claim. It is necessary to pursue additional development to ensure there is a complete record upon which to decide the appellant’s claim, so that the Veteran is afforded every possible consideration. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one). Accordingly, the Veteran’s sleep disorder claim is remanded in order to obtain medical opinions. 2. Entitlement to service connection for a lung disability, to include as due to an undiagnosed illness is remanded. The Veteran contends he has a lung disability that is related to his active service; specifically, he asserts that he was exposed to environmental hazards during his active service in the Persian Gulf and to asbestos when stationed in Norfolk VA. The Veteran’s STR’s upon entrance and separation show no diagnosis of asthma or pulmonary disorders in service. However, under 38 C.F.R. § 3.303 (d), disorders diagnosed after discharge may also still be service connected if all the evidence, including pertinent service records, establishes the disorder was incurred in service. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In order to fully develop the Veteran’s service connection claims, in December 2016 the Veteran underwent a VA respiratory examination. The Veteran had a current diagnosis of asthma and the examiner opined that the Veteran’s claimed lung condition was less likely than not related to Gulf War illness or due to an exposure event in Southwest Asia as the Veteran had been diagnosed with asthma, which the examiner classified as a disease with a clear and specific etiology. See December 2016 VA Gulf War General Medical Examination DBQ. With regard to service connection through the Gulf War presumption, the Veteran served during the Gulf War and suffers from a current diagnosis of asthma. However, asthma is not a qualifying Gulf War chronic condition as defined by the Regulations. The Regulations require either an undiagnosed illness or a medically unexplained chronic multi symptom illness in order to qualify for the Gulf War presumption. Asthma is neither undiagnosed nor unexplained. Accordingly, the Veteran’s Gulf War status does not establish presumptive Gulf War service connection with regard to his current diagnosis of asthma. Service connection can sometimes be demonstrated through chronicity. The Veteran’s lung disorder is not an enumerated “chronic disease” listed under 38 C.F.R. § 3.309 (a); therefore, the presumptive provisions based on “chronic” symptoms in service and “continuous” symptoms since service at 38 C.F.R. § 3.303 (b) do not apply here. Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). The record contains evidence pertinent to the Veteran’s direct service connection claim. In August 2016 the Veteran submitted a statement describing that his job duties included working on the flight deck securing aircraft returning from flying missions over Iraq and Kuwait during the Gulf War. The Veteran contends that he was exposed to chemicals and/or biological hazards on these aircraft. In addition, the Veteran contends that at his home port in Norfolk VA one of his assigned duties was to clean dirt off asbestos wrapped pipes. The Veteran indicated that in 1993 when discharged from service he began to notice shortness of breath and experienced violent coughing episodes, among other symptoms. In developing evidence pertinent to the direct service connection claim, the RO obtained a January 2017 asbestos addendum opinion with respect to whether the Veteran’s asthma was due to exposure to asbestos during his active service. The examiner opined that the Veteran’s asthma disability was less likely than not due to his active service because a chest x-ray was negative, there was no asbestos-related lung disease, and because “current studies do not link asbestos exposure with the etiology of asthma.”. In April 2017, the Veteran underwent a second VA respiratory examination. Despite specifying that the Veteran did not have multiple respiratory conditions, the examiner opined that “[w]hen looking that the Veteran’s history for tobacco use, it is my medical opinion that he has COPD not asthma, and this condition was caused by tobacco use not anything associated with his medical service.” See April 2017 VA Medical Opinion DBQ. This medical opinion was disputed when the Veteran testified in May 2019 that he primarily used chewing tobacco and did not smoke cigarettes regularly. See May 2019 Board Hearing Transcript. A review of the medical evidence of record reflects that in January 2017, the Veteran reported to VA doctors that he had used smokeless tobacco for 32 years before quitting over five years prior. See January 2017 VA NWIHS Pharmacy Note. Further, the Veteran submitted medical treatment records documenting his asthma symptoms. The direct service connection claim includes consideration of the Veteran’s testimony. In May 2019 the Veteran testified that he was treated in service for bronchitis in February of 1992 when he was serving aboard the aircraft carrier USS John F Kennedy. He testified that he believes some time in 1997 he sought medical attention because he could not breathe. He went to the emergency room. The Veteran testified that he did not recall any other asthma attacks or attacks of shortness of breath between the time he separated from active service until he started treatment for asthma from the VA. With regard to possible exposure to asbestos, the Veteran testified that he does not recall responding to a five question VA questionnaire that was sent to him with regard to his claim of asbestos exposure. The Veteran also testified that he lost consciousness several times while serving on the aircraft carrier, and at the end of his service in March 1993 the separation physical reflects unexplained loss of consciousness. In light of the Veteran’s subsequent Board testimony as well as the Veteran’s submission of additional medical evidence, the Board remanded the Veteran’s asthma claim for a new VA opinion in September 2019. To support his direct service claim, in August 2020 the Veteran submitted a statement from Mr. WM, who served on active duty along with the Veteran when they were stationed aboard the USS John F Kennedy working on the flight deck. Mr. WM stated that both he and the Veteran were breathing JP 5 jet fuel and exhaust particulates which Mr. WM alleges contains a fire retardant that has caused lung function problems for him. Mr. WM believed that his current asthma diagnosis is connected to his service-connected military occupation specialty (MOS) working with the JP 5 jet fuel. In addition to working with JP 5 jet fuel, in August 2016 the Veteran submitted a statement possible exposure to chemicals and/or biological hazards and asbestos wrapped pipes. He reported shortness of breath and violent coughing in 1993 when discharged from service. It is noted that the Veteran’s MOS listed on his DD214 is ABH - Aviation Boatswain’s Mates, Aircraft Handling. This includes preparing and fueling naval aircraft planes prior to take-off and after landing. Although the Board sincerely regrets the further delay, another remand is required with regard to the Veteran’s asthma claim. It is necessary to pursue additional development to ensure that there is a complete record upon which to decide the appellant’s claim, so that the Veteran is afforded every possible consideration. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one). Accordingly, the Veteran’s asthma claim is remanded in order to obtain medical opinions. There are several aspects of the Veteran’s lung disorder that have not been adequately addressed and for that reason the examinations undertaken after the May 2019 remand are not adequate. The Board requires a medical examination that discusses these issues in order to thoroughly evaluate the Veteran’s asthma claim. First, a February 2020 medical summary reflected that a chest x-ray was undertaken in December 2019 and a mild obstructive lung defect was observed. Clarification is needed in as much as the examiner did not give any additional information regarding the nature and etiology of the Veteran’s mild obstructive lung defect noted here. See C & P exam dated February 7, 2020. Second, with regard to the Veteran’s contention of possible asbestos exposure, the examiner’s opinion does not address the aforementioned mild obstructive lung defect with regard to indicators of asbestos exposure. See C & P exam dated January 14, 2020 associated with the file February 7, 2020. In addition, the Veteran testified at his hearing that he did not recall seeing VA letters addressing exposure to asbestos and asking five specific questions. Third, no examiner has addressed the Veteran’s contentions that his daily exposure to JP 5 jet fuel, along with any chemical or biological toxins on the surfaces of the aircraft, may have played a role in his currently diagnosed asthma. In July 2020, a VA examiner (erroneously) observed “There was never any mention of toxic inhalants while (on) active duty, nor subsequent to that, typical of those service members who had inhalation events over time.” See C & P exam dated 07/27/2020. The examiner’s report accordingly is not adequate because the examiner failed to address the Veteran’s contentions regarding exposure to burned and unburned JP5 jet fuel and other possible agents on the exterior of the airplanes he worked with daily while in active service. Finally, the Veteran reported that while serving aboard the aircraft carrier he was treated for bronchitis in February 1992 and lost consciousness several times. At separation in March 1993 the physical reflects unexplained loss of consciousness. In 1993 when discharged from service Veteran reports shortness of breath and violent coughing episodes. In 1997 he went to the emergency room due to difficulty breathing. In 2016 the Veteran was formally diagnosed with asthma. The examiner should discuss these Veteran reports in conjunction with onset and progression of his currently diagnosed asthma disability. To support his contentions, the Veteran is permitted to associate with the file any available evidence with regard to records, articles, lay statements and/or medical, technical or other literature that might tend to support the Veteran’s contentions with regard to claimed health effects from exposure to jet fuel and substances on the exterior of the combat jets he serviced. It is VA’ s duty to assess the current state of medical knowledge on the subject, including the articles submitted by the Veteran. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010) (examiner may have duty to conduct research in the medical literature before rendering an inconclusive opinion). The Board cannot make determinations based on its own medical judgment. See Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board notes that in order for service connection to be granted, the in-service event need not be the sole or primary cause of the disorder but need only be a contributing cause. Accordingly, after consideration of the evidence, the service connection claim for the Veteran’s asthma disability is remanded. The matters are REMANDED for the following action: 1. The RO is asked to review the contents of this remand. If any additional VA treatment records are outstanding, please associate them with the claims file. The RO should work with the Veteran regarding exposure to asbestos questionnaire referenced by the Veteran during his testimony at the hearing. Please ensure this development is accomplished before scheduling the medical examinations. 2. If an opinion is inadequate, because the examiner reports they are not qualified to render the opinion, offers contradictory or unsupported reasoning, or for any other reason, please take remedial action. 3. The Veteran should be scheduled for VA examinations in the appropriate specialty or specialties to address the Veteran’s service connection claims for a sleep disorder and for asthma. The examinations should include any diagnostic testing or evaluation deemed necessary. The electronic claims file, including a copy of this remand, must be made available for the examiner to review. The Veteran must be interviewed. The Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. The examiner must provide a clear, unequivocal opinion along with medical explanations and reasoning, to include any comment on any credibility issues raised by the record from a medical perspective. Based upon a review of the entirety of the claims file, the history previously presented by the Veteran, and the examination results as to each claimed condition, the examiner is requested to provide an opinion as to the Veteran’s service connection claims for a sleep disorder and asthma. In addition to general file review, the examiner is asked to carefully review this remand, the medical DBQ’s of record, and the Veteran’s statements. After the review, the examiner is asked to issue a definitive and unequivocal opinion based on sound medical reasoning and with reference to the evidence in the claims file. With regard to the claimed service connection for a sleep disability: (a.) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s sleep disability is related to a Persian Gulf War undiagnosed illness as a result of his active service in Southwest Asia? (b.) If the answer to (a.) is negative, is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s sleep disability is directly related to his service because it began during, or is otherwise related to the Veteran’s active duty service? With regard to the claimed service connection for asthma disability: (a.) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s asthma disability is related to a Persian Gulf War undiagnosed illness as a result of his active service in Southwest Asia? (b.) If the answer to (a.) is negative, is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s asthma disability is directly related to his service because it began during, or is otherwise related to the Veteran’s active duty service? (c) In addition to evidence that the examiner finds pertinent or illustrative, please specifically comment upon the following evidence: Please comment on the nature and etiology of the Veteran’s mild obstructive lung defect noted on a chest x-ray in December 2019. Please specifically address any positive or negative correlation to asbestos exposure, onset or occurrence of asthma, exposure to jet fuel and/or other agent(s). Please comment on the Veteran’s contentions regarding claimed health impacts caused by his inhalation of burned and unburned JP5 jet fuel and other possible agents on the exterior of the airplanes he worked with daily while in active service. In July 2020, a VA examiner mentioned toxic inhalants while on active duty and/or inhalation events over time in the context of an evaluation. C & P exam dated 07/27/2020. Please comment on the Veteran’s contentions regarding claimed indicators with regard to onset and progression of his currently diagnosed asthma disability. The Veteran reported that while serving aboard the aircraft carrier he was treated for bronchitis in February 1992 and lost consciousness several times. At separation in March 1993 the physical reflects unexplained loss of consciousness. In 1993 when discharged from service Veteran reports shortness of breath and violent coughing episodes. In 1997 he went to the emergency room due to difficulty breathing. In 2016 the Veteran was formally diagnosed with asthma. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, with reasons. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.M. Schneider 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.