Citation Nr: 21012269 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 10-40 216 DATE: March 4, 2021 ORDER Entitlement to service connection for a headache disability is denied. Entitlement to service connection for a sinus disability is denied. Entitlement to a compensable rating prior to November 22, 2016, and a rating in excess of 10 percent as of November 22, 2016, for appendectomy scar residuals is denied. REMANDED Entitlement to service connection for gastrointestinal disability is remanded. FINDINGS OF FACT 1. The preponderance of evidence is against a finding that the Veteran has a headache disability separate from service-connected obstructive sleep apnea. 2. The preponderance of evidence is against a finding that the Veteran has a sinus disability. 3. Prior to November 22, 2016, a residual appendectomy scar was shown to be manifested by pain, instability, or to encompass 6 square inches or more in area. 4. As of November 22, 2016, a residual appendectomy scar has not been shown to be manifested by three or four scars that are unstable, or to encompass 6 square inches or more in area. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a headache disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385. 2. The criteria for entitlement to service connection for a sinus disability have not been met. 38 U.S.C. § §§ 1101, 1110; 38 C.F.R. § §§ 3.102, 3.303. 3. The criteria for entitlement to a compensable rating prior to November 22, 2016; and a rating in excess of 10 percent as of November 22, 2016 for appendectomy scar residuals have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.10, 4.40, 4.118, Diagnostic Codes 7800-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1991 to May 1995. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a December 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. In November 2016, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record. In May 2017 and December 2019, the Board remanded these claims to the Agency of Original Jurisdiction for additional action. Service Connection Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in-service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Secondary service connection may be established for a disability that is proximately due to, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and may provide sufficient support for a claim of service connection. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is competent to provide testimony concerning factual matters of which he has firsthand knowledge, such as experiencing a physical symptom such as pain. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Therefore, the Board must assess the competence and credibility of lay statements. Barr v. Nicholson, 21 Vet. App. 303 (2007). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while weight and credibility are factual determinations going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). While the Board must provide reasons and bases supporting a decision, there is no need to discuss, in detail, the evidence submitted by or on behalf of the Veteran. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000). 1. Entitlement to service connection for a headache disability. The Veteran contends that he has a headache disability that is due to in-service asbestos exposure. In the alternative, the Veteran contends that a current headache disability is secondary to service-connected obstructive sleep apnea. The Board notes that asbestos exposure has been conceded by VA. However, the Board finds that the competent medical evidence of record does not demonstrate a separate headache disability that is medically distinct from the already service-connected obstructive sleep apnea. Therefore, as there is no medical evidence of a current disability, the Board finds that service connection for a headache disability is not warranted, and the claim must be denied. The threshold consideration for any service connection claim is the existence of a current disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). A close review of the medical evidence of record, to include post-service treatment records and a VA examination from February 2020, shows no diagnosis of a separate headache disability caused by or aggravated by obstructive sleep apnea. The service medical records show no medical incidents in service regarding a headache disability, and a review of post-service records notes no formal diagnosis of a separate headache disability. The Veteran has not submitted any competent evidence that demonstrates a diagnosis of a chronic headache disability during the claim period. At a February 2020 VA examination, the examiner found that the Veteran did not have and had not ever had a diagnosed headache condition. The examiner opined that the claimed headache condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness as transient asbestos exposure is not known to cause headaches. The VA examiner further opined that the claimed condition was not at least as likely as not (50 percent or greater probability) proximately due to or the result of the service-connected disability. The examiner explained that the headache condition was part of the overall symptomatology from obstructive sleep apnea for which the Veteran was service-connected. The examiner stated that it is well known and documented that morning headaches were attributed to sleep apnea. The Veteran had evidence that he complained of frequent morning headaches while he was being evaluated for the obstructive sleep apnea. The examiner opined that, regardless of an established baseline, the Veteran’s headache disability was not at least as likely as not aggravated beyond the natural progression by service-connected obstructive sleep apnea. The examiner reasoned that the use of a CPAP machine eliminated sleep apnea, therefore, treated other secondary symptoms like the headaches. The Board notes that, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2); Bruce v. West, 11 Vet. App. 405 (1998) (one not a medical expert is nevertheless competent to offer evidence of his symptoms in support of a claim for an increased rating); Layno v. Brown, 6 Vet. App. 465 (1994). The Board acknowledges that the Veteran has claimed that he has a disability manifested by headaches and testified to that during a November 2016 Board hearing. However, the Board finds that the Veteran, as a lay person, is not competent to provide a diagnosis for a complex disability dealing with neurologic issues, and thus is not competent to diagnose a chronic headache disability. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent evidence concerning the nature and etiology of the Veteran’s claimed chronic headache disability has been provided by medical professionals who have examined him, and the underlying medical history of his condition, and found no current clinically diagnosed headache disability. To the extent that there is a conflict between the lay and medical evidence, the Board finds the observations and findings of a skilled professional to be more probative than any lay assertions in this case. Accordingly, the February 2020 VA opinion is found to carry significant weight and to be the most persuasive evidence of record. Under applicable regulations, the term disability means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; Hunt v. Derwinski, 1 Vet. App. 292 (1991); Allen v. Brown, 7 Vet. App. 439 (1995). Congress has specifically limited entitlement to service-connected benefits to cases where there is a current disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Notably, none of the competent evidence of record demonstrates that the Veteran is currently diagnosed with a separate disability related to a headaches. In the absence of a diagnosis of a current disability, or any abnormality which is attributable to some identifiable disease or injury during service, an award of service connection is not warranted. The presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). Because there was no actual disability diagnosed at any time since the claim was filed or contemporary to the filing of the claim, and there remains no current evidence of the claimed disability, no valid claim for service connection for a separate disability related to a headache disability exists. Therefore, the claim of service connection for a headache disability must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a sinus disability The Veteran contends that he is entitled to service connection for a current sinus disability that he experiences as a result of exposure to asbestos during active service. VA has conceded probable exposure to asbestos based on the Veteran’s service. The Board finds that the evidence of record does not show that the Veteran has a currently diagnosed chronic sinus disability. Therefore, as the preponderance of evidence is against a finding that the Veteran has a current chronic sinus disability or has had a claimed sinus disability contemporary to the claims period, the claim for service connection must be denied. The threshold consideration for any service connection claim is the existence of a current disability. In the absence of proof of a present disability, there is no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Here, the evidence of record shows no evidence of a current chronic sinus diagnosis. The service medical records were reviewed and show no treatment for or diagnosis of chronic sinus problems while in-service. Post-service treatment records from December 2016 and January 2017 show the Veteran was diagnosed with and treated for sinusitis. However, an analysis of post-service medical records shows no diagnosed chronic sinus disability, to include on VA examinations. The Veteran has not submitted any competent evidence that demonstrates a diagnosis of a chronic sinus disability during the claim period. During VA examination in February 2020, the Veteran was acknowledged to have been treated for acute sinusitis as recently as September 2017. The examiner noted that X-Rays from February 2020 showed limited visualization of the maxillary sinuses on the waters projection without definite evidence of sinusitis. The examiner remarked that the Veteran was never diagnosed to have any chronic sinusitis conditions and that the acute sinusitis diagnosed by the private medical providers had resolved without any development of chronic symptoms related to the condition. The examiner opined that the Veteran’s claimed sinus 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 explained that the Veteran was never diagnosed to have any chronic sinusitis conditions and had previous acute sinusitis which resolved based on review of the medical records and the Veteran’s recent sinus X-Rays. The Board notes that, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a)(2); Bruce v. West, 11 Vet. App. 405 (1998) (one not a medical expert is nevertheless competent to offer evidence of his symptoms in support of a claim for an increased rating); Layno v. Brown, 6 Vet. App. 465 (1994). The Board acknowledges that the Veteran has claimed that he has a disability manifested by sinus trouble and testified to such during a November 2016 Board hearing. However, the Board finds that the Veteran, as a lay person, is not competent to provide a diagnosis for a complex disability dealing with sinus issues, and thus is not competent to diagnose a chronic sinus disability. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent evidence concerning the nature and etiology of the Veteran’s claimed chronic sinus disability has been provided by a medical professional who has examined him, and the underlying medical history of his condition, and found no current clinically diagnosed sinus disability. To the extent that there is a conflict between the lay and medical evidence, the Board finds the observations and findings of a skilled professional to be more probative than any lay assertions in this case. Accordingly, the February 2020 VA opinion is found to carry significant weight and to be the most persuasive evidence of record. Furthermore, even if the Board were to consider the acute manifestations of sinusitis, the February 2020 VA examination found that it was less likely as not that any sinus condition was related to service. The Veteran has not submitted contrary competent evidence that supports the claim. In the absence of competent medical evidence finding a current, chronic sinus disability, the threshold requirement for substantiating the claims for service connection is not met. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board is appreciative of the Veteran’s faithful and honorable service to our country. The Board acknowledges that VA is statutorily required to resolve reasonable doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. However, the Board finds that the preponderance of the evidence is against a finding of any current diagnosis for a chronic sinus disability related to active service. Therefore, the claim of service connection for a sinus disability must be and is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to a compensable rating prior to November 22, 2016, and a rating in excess of 10 percent as of November 22, 2016, for appendectomy scar residuals Disability ratings are based on VA’s Schedule for Rating Disabilities. 38C.F.R. Part 4. Separate Diagnostic Codes identify various disabilities and the criteria for a specific percentage rating to be assigned for that disability. The percentage ratings represent as far as practicably can be determined the average impairment in earning capacity due to a service-connected disability. 38 U.S.C. § 1155. A rating is assigned by comparing the extent to which a service-connected disability impairs the ability to function under the ordinary conditions of daily life, as demonstrated by the symptomatology, with the criteria for the percentage ratings. 38 U.S.C. §1155; 38 C.F.R. §4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Disabilities must be reviewed in relation to their history. 38C.F.R. §4.1. Examination reports must be interpreted, and if necessary reconciled, into a consistent picture so that the rating may accurately compensate the elements of disability present. 38 C.F.R. § 4.2. If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Board must determine the probative weight to be assigned among evidence in a case, and to state reasons or bases for favoring one opinion over another. Winsett v. West, 11 Vet. App. 420 (1998). If all the evidence is in relative equipoise, reasonable doubt shall be resolved in the Veteran’s favor, and the claim should be granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. If the preponderance of the evidence is against the claim, the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A service-connected appendectomy scar is rated 0 percent prior to November 22, 2016, and 10 percent disabling as of November 22, 2016, pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7804. Diagnostic Code 7805 provides that scars (including linear scars) not otherwise rated under Diagnostic Codes 7800-7804 are to be rated based on any disabling effects not provided for by those codes. In addition, the effects of scars otherwise rated under Diagnostic Codes 7800-7804 are to be considered. Diagnostic Code 7801 provides that burn scars or scars due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 square centimeters) but less than 12 square inches (77 square centimeters) will be assigned a 10 percent rating. A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7802 pertains to burn scars or scars due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 square centimeters) or greater will be assigned a 10 percent rating. A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7804 pertains to unstable or painful scars. One or two scars that are unstable or painful are rated at 10 percent disabling. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118. VA amended the criteria for rating skin disabilities effective August 13, 2018. However, Diagnostic Code 7805 was not changed by the August 13, 2018, amendments. A July 2009 private examination found a right-sided lower abdomen scar, approximately 11 centimeters long that progressed parallel to the inguinal ligament and approximately 2 centimeters above it. The scar was slightly above the level of the skin and was straight, with somewhat darker brownish pigmentation. There were no induration, dehiscence, or external signs of inflammation. The scar demonstrated good mobility on the underlying fatty tissue. No pain was triggered on palpation of the scar. There was no hypersensitivity or trophic disturbances. In a November 2016 administrative note, the Veteran complained of scar tenderness and pain with movement. During a November 2016 Board hearing, the Veteran complained of constant scar pain and tenderness. A December 2016 primary care note recorded the Veteran complaining about abdominal pain along the appendix scar for several months. The Veteran complained of pain when twisting and turning and discomfort with palpation. A February 2017 physical therapy note describes the Veteran as having right lower quadrant intermittent pain along the scar. The Veteran’s abdominal region was tender above, below, and over the appendectomy scar. At an August 2017 VA examination, the Veteran was noted as having a linear scar on the anterior trunk measuring 11 by 1 centimeters in size. The scar was noted as being painful to touch. A February 2018 primary care note describes the Veteran as having abdominal pain along the appendix scar for several months. The Veteran complained of pain due to twisting and turning and palpation. A CT scan of the abdomen and pelvis was normal. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating for appendectomy scar residuals, prior to November 22, 2016, and in excess of 10 percent as of November 22, 2016, under the applicable Diagnostic Codes. The Board notes that Diagnostic Code 7800 is not applicable because that is used to rate impairment resulting from disfigurement of the head, face, or neck, and the scars are on the abdomen. Diagnostic Codes 7801 and 7802 are not for application as the service-connected appendectomy scar does not cover an area of at least 6 square inches. Diagnostic Code 7805 is not for application as the appendectomy scars has not been shown to result in limitation of function. Based on the evidence, the Board finds that an increased rating is not warranted. Considering the record as a whole, and resolving any reasonable doubt in favor the Veteran, the Board finds that the Veteran does not meet the criteria for a compensable rating prior to November 22, 2016, under Diagnostic Code 7804 as the appendectomy scar was not shown to be manifested by pain or instability. Prior to November 22, 2016, the medical evidence of record did not find the appendectomy scar to be painful or unstable. Effective November 22, 2016, taking into consideration the record as a whole, and resolving any reasonable doubt in favor the Veteran, the Board finds that the Veteran does not meet the criteria for a rating in excess of 10 percent disabling pursuant to Diagnostic Code 7804, as the Veteran was not shown to have three or four scars that are unstable or painful commensurate with an increased rating. No additional higher or alternative ratings under a different Diagnostic Code can be applied in this case. The Veteran's appendectomy scar does not affect his head, face or neck, is not deep, and is not of an area greater than 6 square inches. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7802. There is also no evidence of limitation of motion or function of the affected parts attributable to the abdominal scar. 38 C.F.R. § 4.118, Diagnostic Code 7805. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating compensates. However, he does not assert, and medical records do not show, that the appendectomy scar is manifested by any disabling effects not considered in a rating provided under Diagnostic Codes 7800-7805. Although the Board is sympathetic to the Veteran's claim, the criteria for an award of an increased rating for his appendectomy scar have not been met. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating for appendectomy scar residuals, prior to November 22, 2016; and in excess of 10 percent as of November 22, 2016, under the applicable Diagnostic Codes. Although the Board recognizes the Veteran's honorable service on behalf of the country, in light of the evidence discussed above, there is no basis upon which to award an increased rating. Accordingly, as the preponderance of the evidence is against the assignment of any higher ratings, the claim for an increased rating must be denied. 38 C.F.R. § 4.3; 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a gastrointestinal disability is remanded. Although the Board regrets the delay, additional development is needed prior to further disposition of the claim of entitlement to service connection for a gastrointestinal disability. The Veteran contends that a current gastrointestinal disability is the residual of appendectomy surgery during service. VA’s duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121 (1991). When VA obtains an evaluation, the evaluation must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran was last provided a VA examination in February 2020. During that examination, the Veteran was not found to have any stomach or duodenum condition. However, the examiner noted that the Veteran was on continuous medication for a diagnosed condition and had signs and symptoms of stomach or duodenum condition. The February 2020 VA examiner opined that it was less likely than not (less than 50 percent probability) that the claimed condition was incurred in, or caused by the claimed in-service injury, event, or illness. The examiner explained that there were no stomach conditions diagnosed in service based on the symptoms currently mentioned. There were no private medical records or VA medical records to show that the Veteran was diagnosed with any stomach conditions in service based on the symptoms and complaints of record. In an August 2020 addendum opinion, the same examiner from February 2020, opined that the claimed condition was less likely than not (less than 50 percent probability) proximately due to or the result of the service-connected appendectomy scar. The examiner reasoned that there were no recorded medical conditions related to any residuals from the Veteran’s appendectomy found in the medical records in service or post- service. The Board finds the February 2020 and August 2020 examinations and opinions to be based on an inaccurate factual premise, and as a result, to be inadequate for VA purposes. The examiner stated that the Veteran was not found to have any stomach or duodenum condition. However, there is medical evidence of record that shows the Veteran was being treated for colitis in February 2010 and January 2017. Accordingly, the Board finds the February 2020 and August 2020 examinations relied on a factually inaccurate premise that no gastrointestinal disabilities were shown in the record. Accordingly, as the February 2020 and August 2020 examinations have been found inadequate, and there are no other etiology opinions of record, remand is necessary for an adequate etiology opinion regarding the alleged gastrointestinal disability and service. The Veteran is notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. § 3.655. The matters are REMANDED for the following action: 1. Contact the Veteran and request that he provide information as to treatment for all the claimed gastrointestinal disabilities, including the names and addresses of all health care providers whose records have not already been provided to VA. On receipt of the requested information and the appropriate releases, contact all identified health care providers and request copies of all available records pertaining to treatment of the Veteran, not already of record. If identified records are not obtained, then notify the Veteran. 38 C.F.R. §3.159(e). 2. Schedule the Veteran for a VA examination, with an examiner who has not previously examined the Veteran, to diagnose and determine the nature and etiology of any gastrointestinal disability. The examiner must review the claims file, including this Remand and the December 2019 Board remand, in its entirety and should note that review in the report. The examiner should address the lay statements of record regarding the claimed disability and its etiology. The examiner is advised that the Veteran is competent to report symptoms and history and that those reports must be acknowledged and considered in formulating any opinion. If the Veteran’s reports are discounted, the examiner should provide a reason for doing so. The examiner should diagnose all gastrointestinal disabilities found or shown in the record during the pendency of this claim. The examiner should reconcile the diagnosis with the previous evidence of record. For each diagnosed gastrointestinal disability found, to specifically include the colitis for which the Veteran has been treated, the examiner must opine whether it is at least as likely as not (50 percent or greater probability) that each gastrointestinal disability is etiologically related to active service or any event, disease, or injury during service, including whether the gastrointestinal disability (1) began during active service, (2) was noted during service with continuity of the same symptomatology since service, (3) was caused by any service-connected disability or treatment for any service-connected disability, to include appendectomy scars, or (4) has been aggravated (increased in severity beyond the natural progress of the disorder) by any service-connected disability or treatment for any service-connected disability, to include appendectomy scar. The examiner must discuss the significance, if any, of the Veteran’s in-service appendectomy on the currently claimed gastrointestinal issues. The examiner must also discuss the significance, if any, of the February 2010, and January 2017 private treatment records indicating a colitis diagnosis on the currently claim for service connection for a gastrointestinal disability. The examiner should reconcile the opinion with any previous opinions of record. A clearly stated rationale for each opinion offered must be provided and must not be based solely on the lack of an in-service record of the claimed disability. Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mondesir, Eric 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.