Citation Nr: 21012363 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 18-05 170 DATE: March 4, 2021 ORDER New and material evidence having been received, the claim of entitlement to service connection for a low back disorder is reopened. New and material evidence having been received, the claim of entitlement to service connection for bilateral pes planus is reopened. Entitlement to service connection for a nutritional deficiency, to include as secondary to hypothyroidism, is denied. REMANDED Entitlement to service connection for xerosis (skin disorder), to include as secondary to hypothyroidism, is remanded. Entitlement to service connection for dermatitis (skin disorder), to include as secondary to hypothyroidism, is remanded. Entitlement to service connection for anemia, to include as secondary to hypothyroidism, is remanded. Entitlement to service connection for an eye disorder (other than dry eyes), including presbyopia, to include as secondary to hypothyroidism, is remanded. Entitlement to service connection for headaches, to include as secondary to schizophrenia and/or hypothyroidism, is remanded. Entitlement to service connection for hypertension, to include as secondary to hypothyroidism, is remanded. Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, claimed as radiculopathy and hand numbness, to include as secondary to a low back disorder, is remanded. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, claimed as radiculopathy and leg/knee numbness, to include as secondary to a low back disorder, is remanded. Entitlement to service connection for shoulder height inequality/deformity (also claimed as leg length discrepancy) is remanded. Entitlement to service connection for bilateral pes planus is remanded. Entitlement to service connection for follicular cysts of the ovaries and Nabothian cyst of the cervix, to include as secondary to hypothyroidism, is remanded. Entitlement to an initial compensable rating for acne is remanded. Entitlement to an initial compensable rating for alopecia is remanded. FINDINGS OF FACT 1. An April 1993 rating decision denied the claims for entitlement to service connection for a low back disorder and bilateral pes planus; the Veteran did not complete a substantive appeal to that decision, and it is final. 2. Some of the evidence received since the April 1993 rating decision pertinent to the claims for service connection for a low back disorder and bilateral pes planus was not previously submitted, relates to an unestablished fact necessary to substantiate the claims, is neither cumulative nor redundant, and raises a reasonable possibility of substantiating the claims for service connection. 3. The Veteran does not have a nutritional deficiency disability. CONCLUSIONS OF LAW 1. An April 1993 rating decision that denied the claims of entitlement to service connection for a low back disorder and bilateral pes planus is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. Evidence received since the April 1993 rating decision is new and material, and the Veteran’s claims for service connection for a low back disorder and bilateral pes planus are reopened. 38 U.S.C. §§ 5108; 38 C.F.R. § 3.156. 3. The criteria for service connection for a nutritional deficiency, to include as secondary to hypothyroidism, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from April 1988 to December 1992 and January 1998 to September 2002. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from September 2013, April 2016, and September 2016 rating decisions. The Veteran requested a hearing before the Board. The requested hearing was conducted in March 2020 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. The Veteran also has pending appeals for eduction benefits; these issues will be addressed in separate Board decisions. Petitions to Reopen 1. Whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for a low back disorder. 2. Whether new and material evidence has been received to reopen a previously denied claim for entitlement to service connection for bilateral pes planus. The Veteran seeks to reopen her previously denied claims for entitlement to service connection for a low back disorder and bilateral pes planus. Notwithstanding determinations by the RO that new and material evidence has or has not been received to reopen the Veteran’s claims, it is noted that on its own, the Board is required to determine whether new and material evidence has been presented. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (holding that the Board has a legal duty under 38 U.S.C. §§ 5108 and 7104, to address the question of whether new and material evidence has been presented to reopen a previously denied claim); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. In determining whether new and material evidence has been submitted, the Board must consider the specific reasons for the prior denial. Evans v. Brown, 9 Vet. App. 273, 283 (1996). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Claims for entitlement to service connection for a low back disorder and bilateral pes planus were last denied in an April 1993 rating decision on the basis that there was no evidence of current diagnoses of the feet or back. Evidence received since the rating decision consists of multiple statements from the Veteran and medical treatment records. Medical evidence indicates the Veteran has a post-service diagnosis of mild pes planus (April 2017) and has repeatedly been seen and treated for chronic low back pain. In this case, the evidence obtained since the last final denial is new, as it was not previously associated with the record. It is also material because it raises a reasonable possibility of substantiating the claims. The Board determines that the claims are reopened. Service Connection 3. Entitlement to service connection for a nutritional deficiency, to include as secondary to hypothyroidism. The Veteran seeks entitlement to service connection for a nutritional deficiency, to include as secondary to hyperthyroidism. Under the relevant laws and regulations, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons 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); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 4 (1990). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Unfortunately, the probative evidence of record does not demonstrate that the Veteran has a nutritional deficiency disability. The Veteran was afforded a VA examination in February 2017. The examiner noted the Veteran reported various deficiencies. After a review of the file and examination of the Veteran, the examiner noted that there was evidence of a nutritional consultation in 2010, however, there was no consistent objective clinical and/or physical examination data to support that the Veteran has an ongoing nutritional deficiency. The examiner noted that the Veteran’s historic VA labs do have some variable high and low recordings, however, there was no data to suggest a chronic metabolic condition that was secondary to her hypothyroidism. Furthermore, the February 2017 VA examiner also noted that the Veteran did not experience functional impairment as a result of a nutritional deficiency disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Board notes the record contains a Nutritional Deficiency Disability Benefits Questionnaire (DBQ), dated June 2012, stating the Veteran had a nutritional deficiency, with a condition noted as “Vitamin D.” The physician stated the Veteran had a diagnosis of hypothyroidism in 2000 and Vitamin D deficiency in August 2011. The February 2017 VA examiner also noted this DBQ, explaining that there was no causative statement in the DBQ and although there is literature to support a correlation between severe hypothyroidism and Vitamin D deficiency, VA records show the Veteran has been, for the most part, euthyroid while taking supplementation. Additionally, a Vitamin D deficiency is not a disability within the meaning of the applicable legislation. The term “disability” means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1. A vitamin D deficiency is a laboratory test finding. To the extent that the deficiency causes fatigue or other symptoms, as noted, the medical evidence indicates the Veteran does not experience functional impairment. See April 2017 VA examination. In light of the above, the Board finds that the Veteran has not had a separate nutritional deficiency disability at any point during the pendency of the appeal or any disability or functional loss due to a nutritional deficiency disability. To the extent that the Veteran believes that she has a current nutritional deficiency disability, she is not competent to provide a diagnosis in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). A diagnosis of a nutritional deficiency disability requires expertise that the Veteran has not established. Therefore, the Board gives more probative weight to the competent medical evidence. In the absence of competent evidence that the Veteran has a current nutritional deficiency disability, the criteria for establishing service connection have not been established. 38 C.F.R. § 3.303. REASONS FOR REMAND 4. Entitlement to service connection for xerosis, to include as secondary to hypothyroidism, is remanded. 5. Entitlement to service connection for dermatitis, to include as secondary to hypothyroidism, is remanded. 6. Entitlement to service connection for anemia, to include as secondary to hypothyroidism, is remanded. The Veteran asserts that her skin disorders, xerosis and dermatitis, are secondary to her hypothyroidism. She also asserts that her anemia is secondary to her hypothyroidism. In the alternative, the Veteran asserts that her dermatitis had an onset during service, as a result of exposure to chemicals and dust during field trainings. VA medical opinions were obtained in April 2017. Remand is necessary to obtain a medical opinion for direct service connection for the Veteran’s claimed dermatitis. 7. Entitlement to service connection for an eye disorder (other than dry eyes), including presbyopia, to include as secondary to hypothyroidism. The Veteran seeks entitlement to service connection for an eye disorder, including presbyopia. She asserts her disorder is due to service, or, in the alternative, is secondary to her hypothyroidism. The Board notes the Veteran was afforded a VA examination in December 2012, at which time the examiner stated the Veteran’s “basic problem was presbyopia.” At the time, she also complained of dry eyes, which was later service connected in a December 2017 rating decision. VA regulations specifically prohibit service connection for refractive error of the eyes, which includes presbyopia, unless such error was subjected to a superimposed disease or injury during service that resulted in an additional disability. As noted, the Veteran asserts her vision was affected during field training. As the previous VA examination and opinion does not address whether the Veteran’s presbyopia was superimposed upon by a disease or injury in service, remand is warranted for an addendum opinion. Additionally, the Veteran has asserted various eye symptoms, such as bulging eyes and eye pain, as secondary to her service-connected hypothyroidism. On remand, a medical opinion should be obtained regarding these symptoms. 8. Entitlement to service connection for headaches, to include as secondary to hypothyroidism and/or schizophrenia. The Veteran seeks entitlement to service connection for headaches. She asserts her headaches began during service, and also that her hypothyroidism causes headaches. The Veteran was afforded a VA examination and a medical opinion was obtained in February 2017. The examiner left the question of whether the Veteran had a headache condition unanswered. The examiner then opined that the Veteran’s headaches were less likely than not due to service as she had “multiple co-morbid conditions (medical and emotional) along with general life stressors that can impact the occurrence of headaches. There was no objective data to support that her current headaches are a chronic continuation of her active duty service.” Of note, the Veteran is service connected for schizophrenia and hypothyroidism. The Board finds an addendum opinion is necessary that discusses whether the Veteran’s headaches are secondary to any service-connected disability and contains a thorough rationale. 9. Entitlement to service connection for hypertension, to include as secondary to hypothyroidism. The Veteran seeks entitlement to service connection for hypertension. Of note, a June 2010 VA treatment note states that the Veteran’s hypothyroid “explains” her diastolic hypertension. Subsequent treatment notes continue to indicate the Veteran has an active diagnosis of hypertension, although several of the reports indicate her hypertension is an active problem but controlled. She was afforded a VA examination in March 2016, at which time the examiner stated the Veteran had a diagnosis of hypertension in 2010. The examiner stated that the Veteran had labile hypertension dating back several years (not sustained); the readings demonstrated labile hypertension but not sustained hypertension. The examiner opined that the Veteran’s claimed hypertension was less likely than not related to her hypothyroidism since she is not hypothyroid and blood pressure readings were normal and not indicative of chronic sustained hypertension, at this time. Although the Veteran did not have high blood pressure readings at the March 2016 VA examination, the Board notes that VA treatment records indicate the Veteran had a diagnosis of hypertension during the appeal period. Importantly, service connection may be granted for a disability shown and resolved during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board finds an addendum opinion is necessary. 10. Entitlement to service connection for a low back disorder. 11. Entitlement to service connection for peripheral neuropathy of the bilateral upper extremities, claimed as radiculopathy and hand numbness, to include as secondary to a low back disorder. 12. Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, claimed as radiculopathy and leg/knee numbness, to include as secondary to a low back disorder. The Veteran’s claim for a low back disorder has been reopened. The Veteran’s service treatment records indicate that on a November 1992 Report of Medical History for separation from service she complained of recurrent back pain secondary to lifting. VA treatment records indicate the Veteran has complained of back pain on several occasions and has an active problem noted as “low back pain.” The Board finds a remand is necessary to afford the Veteran a VA examination and to obtain a medical opinion. Additionally, the Veteran has claimed entitlement to service connection for peripheral neuropathy/radiculopathy of the bilateral hands and lower extremities, to include as secondary to her low back disorder. The Veteran was afforded a VA examination in February 2017, at which time the examiner indicated the Veteran did not have a diagnosis of a peripheral nerve condition; however, the examiner noted an electromyogram in 2013 did reveal a lumbar radiculopathy on the left. The Veteran testified that she was scheduled for an appointment regarding her back and neuropathy in March 2020. A copy of a portion of the March 2020 VA appointment was submitted by the Veteran; however, on remand, the updated VA treatment records, to include the reported appointment for her low back and neuropathy symptoms should be obtained and associated with the claims file. A medical opinion should also be obtained for the diagnosed left radiculopathy in 2013 and any additionally diagnosed neuropathy. 13. Entitlement to service connection for shoulder height inequality/deformity (also claimed as leg length discrepancy). 14. Entitlement to service connection for bilateral pes planus. Service treatment records indicate that in August 1999, the Veteran was noted to have a 0.5-0.75 centimeter leg discrepancy. She was treated with boot soles. VA treatment notes post service also indicate the Veteran is diagnosed with a leg length discrepancy due to sacroiliac joint disease. See October 2015 VA treatment note. Regarding flat feet, the Veteran’s separation examination from November 1992 noted normal feet with no defect or diagnosis of flat feet. Upon entrance to her second period of service in November 1997, she was noted to have asymptomatic pes planus on the entrance examination. The Veteran was afforded a VA examination; however, at the time, her feet were noted to be normal, with a diagnosis of foot pain, undetermined etiology. An April 2017 VA treatment note indicates the Veteran has a current diagnosis of mild pes planus and decreased muscle strength to both feet. The Veteran testified that she believes training during service, including 25-mile marches with weapons and other excessive training aggravated her leg length discrepancy and bilateral flat feet. On remand, medical opinions should be obtained. 15. Entitlement to service connection for follicular cysts of the ovaries and Nabothian cyst of the cervix, to include as secondary to hypothyroidism. The Veteran seeks entitlement to service connection for follicular cysts and a Nabothian cyst. She asserts she began experiencing symptoms while on active duty. A VA medical opinion was obtained in February 2017, at which time the examiner opined that the Veteran’s menstrual disorders were related to her thyroid condition, but her history of cysts were not related to her military service or her history of menstrual disorders. An addendum opinion was obtained in June 2017. The examiner again opined that the Veteran’s heavy menstrual periods were related to her thyroid disorder. The examiner indicated the Veteran’s Nabothian cyst was a benign cyst on the cervix and not related to her military service. An additional addendum opinion was obtained in November 2017. The examiner stated Nabothian cysts are benign mucous cysts of the cervical mucous glands and are less likely as not to be related to hypothyroidism. Continuing, the examiner stated that egg follicle cysts come and go monthly with the menstrual cycle; if the patient does not ovulate, the cyst may persist for a few months until another cycle occurs. The examiner stated that patients with hypothyroidism occasionally may not ovulate or menstruate every month, so it is possible the Veteran may have had a persistent follicular cyst until her next period occurred. The examiner then opined that a follicular cyst is less likely than not to be related to her hypothyroidism. The Board finds these opinions are not clear and do not contain complete rationales; on remand, an addendum opinion must be obtained that contains a thorough rationale. 16. Entitlement to an initial compensable rating for acne. 17. Entitlement to an initial compensable rating for alopecia. The most recent VA examinations for the Veteran’s acne and alopecia were conducted in March 2016, more than four years ago. The Veteran asserts that her acne and alopecia are more severe than reflected during the prior VA examinations, as she testified that they affect a larger percentage of her body than previously reported in the VA examinations. A remand is necessary to afford the Veteran contemporaneous examinations to determine the current severity of her disabilities. See Allday v. Brown, 7 Vet. App. 517, 526 (1995) (indicating that where the record does not adequately reveal the current state of the claimant’s disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination). The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated treatment records, to include, but not limited to, VA treatment records from McClellan VA Medical Center, North Little Rock, from March 2020 to current. 2. Obtain an addendum opinion for the Veteran’s xerosis. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s diagnosed xerosis is proximately due to or aggravated (beyond a natural progression) by her hypothyroidism? A detailed explanation (rationale) is requested for all opinions provided, citing supporting clinical data and/or medical literature, as appropriate. If it is not possible to provide the requested opinions without resort to speculation, the examiner should explain why that is so. 3. Obtain an addendum opinion for the Veteran’s dermatitis. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: Is it at least as likely as not (i.e., a 50 percent or greater probability): a) that the Veteran’s diagnosed dermatitis had an onset during service, or is causally or etiologically due to service, to include the Veteran’s asserted exposure to dust and chemicals during field training; or, b) is proximately due to or aggravated (beyond a natural progression) by her hypothyroidism? A detailed explanation (rationale) is requested for all opinions provided, citing supporting clinical data and/or medical literature, as appropriate. If it is not possible to provide the requested opinions without resort to speculation, the examiner should explain why that is so. 4. Obtain an addendum opinion for the Veteran’s anemia. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s diagnosed anemia is proximately due to or aggravated (beyond a natural progression) by her hypothyroidism? A detailed explanation (rationale) is requested for all opinions provided, citing supporting clinical data and/or medical literature, as appropriate. If it is not possible to provide the requested opinions without resort to speculation, the examiner should explain why that is so. 5. Obtain an addendum opinion for the Veteran’s claimed eye disorder, to include presbyopia. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: a) Please clarify the Veteran’s diagnosis (other than dry eyes), to include the Veteran’s symptoms of blurred vision, bulging eyes, and eye pain. All current eye diagnoses should be noted in the examination report. b) For each diagnosed eye disorder (other than dry eyes), please indicate whether it is a congenital/developmental defect, congenital/development disease or an acquired disorder. The examiner is advised that for purposes of VA compensation, a congenital defect is defined as a condition that is more or less stationary in nature, whereas a congenital disease is defined as a condition capable of improving or deteriorating. c) If any current eye disorder is a congenital defect, was it subject to, or aggravated by, a superimposed disease or injury during service which resulted in an additional disability? If so, please identify the additional disability. d) In contrast, if any current eye disorder is a congenital disease or an acquired disorder, please state whether it clearly and unmistakably both (i) preexisted the Veteran’s entry into active service, and (ii) was not aggravated beyond the normal progress of the disorder during or as a result of active service (i.e., that it clearly and unmistakably did not increase or that any increase was clearly and unmistakably due to the natural progress of the disease)? If the current eye disorder did not clearly and unmistakably pre-exist the Veteran’s service, is it at least as likely as not (probability of 50 percent or more) that any such eye disorder is related to service, including any incident thereof? e) If it is determined the Veteran’s acquired eye disorder is not causally or etiologically related to service in any way, please opine whether each diagnosed eye disorder is at least as likely as not proximately due to or aggravated (beyond a natural progression) by her service-connected hypothyroidism. In providing these opinions, the examiner must acknowledge and discuss any lay evidence of a chronicity of symptoms. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case, e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc. If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist’s opinion, or other information needed to provide the requested opinion. 6. Obtain an addendum opinion for the Veteran’s headaches. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: Is it at least as likely as not (i.e., a 50 percent or greater probability): a) that the Veteran’s headaches had an onset during service, or is causally or etiologically due to service; or, b) are proximately due to or aggravated (beyond a natural progression) by her hypothyroidism and/or schizophrenia? The examiner should consider and discuss the Veteran’s lay statements regarding the onset and continuity of her headaches, as well as the February 2017 VA examiner’s opinion that the Veteran had “multiple co-morbid conditions (medical and emotional)” that can impact the occurrence of headaches. A detailed explanation (rationale) is requested for all opinions provided, citing supporting clinical data and/or medical literature, as appropriate. If it is not possible to provide the requested opinions without resort to speculation, the examiner should explain why that is so. 7. Obtain an addendum opinion for the Veteran’s hypertension. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: a) Please clarify the Veteran’s diagnosis. If a current diagnosis of hypertension is not established, the examiner must address the previous diagnosis of hypertension during the appeal period and explain whether that diagnosis was in error or has resolved. b) For any current diagnosis or diagnosis during the appeal period that may have resolved, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s hypertension is proximately due to or aggravated (beyond a natural progression) by her hypothyroidism? The examiner should consider and discuss the June 2010 VA treatment note stating that the Veteran’s hypothyroid “explains” her diastolic hypertension as well as subsequent treatment notes that continue to indicate the Veteran has an active diagnosis of hypertension, although several of the reports indicate her hypertension is controlled. A detailed explanation (rationale) is requested for all opinions provided, citing supporting clinical data and/or medical literature, as appropriate. If it is not possible to provide the requested opinions without resort to speculation, the examiner should explain why that is so. 8. Afford the Veteran a VA examination for her low back disorder. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: a) The examiner should diagnose any current low back disorder. b) If no such disability is identified, the examiner must indicate whether the Veteran’s reported low back pain causes any functional impairment. c) For any low back disorder diagnosed, or if it is determined the Veteran’s low back pain causes functional impairment, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder/functional impairment had its onset during the Veteran’s service or is causally or etiologically due to service, to include the reported recurrent low back pain during service in November 1993. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 9. Obtain an addendum opinion for the Veteran’s claimed peripheral neuropathy/radiculopathy of the bilateral upper extremities and bilateral lower extremities. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: a) The examiner should diagnose any current peripheral neuropathy/radiculopathy of the bilateral upper and lower extremities. b) If no such disability is identified, the examiner must indicate whether the Veteran’s reported symptoms cause any functional impairment. c) For any peripheral neuropathy/radiculopathy diagnosed, or if it is determined the Veteran’s symptoms cause functional impairment, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that such disorder/functional impairment: a. had its onset during the Veteran’s service or is causally or etiologically due to service; or, b. is proximately due to or aggravated (beyond a natural progression) by her low back disorder. The examiner must consider and discuss the 2013 EMG demonstrating a left lumbar radiculopathy. A complete rationale should be given for all opinions and conclusions expressed. In the event the examiner cannot provide an opinion without resorting to speculation, it is essential that the examiner provide a rationale for this conclusion (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 10. Obtain a VA medical opinion for the Veteran’s claimed leg length discrepancy/shoulder height inequality. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: a) Please indicate whether the Veteran’s leg length discrepancy/shoulder height inequity is a congenital/developmental defect, congenital/developmental disease or an acquired disorder. b) The examiner is advised that for purposes of VA compensation, a congenital defect is defined as a condition that is more or less stationary in nature, whereas a congenital disease is defined as a condition capable of improving or deteriorating. c) If it is a congenital defect, was it subject to, or aggravated by, a superimposed disease or injury during service which resulted in an additional disability? If so, please identify the additional disability. d) In contrast, if it is a congenital disease or an acquired disorder, please state whether it clearly and unmistakably both (i) preexisted the Veteran’s entry into active service, and (ii) was not aggravated beyond the normal progress of the disorder during or as a result of active service (i.e., that it clearly and unmistakably did not increase or that any increase was clearly and unmistakably due to the natural progress of the disease)? e) If the current disorder did not clearly and unmistakably pre-exist the Veteran’s service, is it at least as likely as not (probability of 50 percent or more) that any such disorder is related to service, including any incident thereof? In providing these opinions, the examiner must acknowledge and discuss any lay evidence of a chronicity of symptoms, to include the Veteran’s asserted theory that training on long marches and carrying heavy weight aggravated her disorder. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved. If it is not possible to provide the requested opinion without resort to speculation, the examiner should state why speculation would be required in this case, e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc. If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist’s opinion, or other information needed to provide the requested opinion. 11. Afford the Veteran a VA examination for her bilateral flat feet. After a review of the claims file and examination of the Veteran, please opine as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s bilateral pes planus had its onset during the Veteran’s first period of service or is causally or etiologically due to her first period of service; or, if not causally or etiologically due to the first period of service, please provide an opinion as to whether it is at least as likely as not (50 percent or higher probability) that the Veteran’s pre-existing bilateral pes planus underwent a permanent worsening during her second period of service (versus a temporary exacerbation of symptoms). The examiner should explain why or why not. If the examiner finds the pes planus was permanently worsened during service, the examiner should opine whether the worsening was clearly and unmistakably the result of the normal progression of the condition. The examiner should explain why or why not. In providing the requested medical opinions, the examiner must acknowledge any symptoms experienced during service and discuss medical and lay evidence of symptoms after service, to include the Veteran’s asserted theory that training on long marches and carrying heavy weight aggravated her disorder. In particular, review the lay statements as they relate to the development of her pes planus and provide information as to how the statements comport with generally accepted medical norms. All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. In providing these opinions, the examiner must acknowledge and discuss any lay evidence of a chronicity of symptoms. 12. Obtain an addendum opinion for the Veteran’s claimed follicular cysts of the ovaries and Nabothian cyst of the cervix from an examiner other than the examiner that provided the February 2017 and November 2017 opinions. If deemed necessary by the examiner, afford the Veteran a VA examination. Based on a full review of the record, to include the Veteran’s lay statements regarding the incurrence and symptomatology of her disorder, please answer the following: Is it at least as likely as not (i.e., a 50 percent or greater probability): c) that the Veteran’s diagnosed follicular cysts and/or Nabothian cyst had an onset during service, or is causally or etiologically due to service; or, d) is proximately due to or aggravated (beyond a natural progression) by her hypothyroidism? The examiner should consider and discuss the in-service symptoms and noted suspected cyst (September 1992), as well as the Veteran’s lay statements regarding the onset and continuity of her symptoms. A detailed explanation (rationale) is requested for all opinions provided, citing supporting clinical data and/or medical literature, as appropriate. If it is not possible to provide the requested opinions without resort to speculation, the examiner should explain why that is so. 13. Afford the Veteran a VA examination to determine the current severity of her alopecia. The Veteran’s claims folder must be reviewed by the examiner. The examiner should identify and completely describe all current symptomatology. 14. Afford the Veteran a VA examination to determine the current severity of her acne. The Veteran’s claims folder must be reviewed by the examiner. The examiner should identify and completely describe all current symptomatology. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Andersen, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.