Citation Nr: 21021703 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 17-46 202 DATE: April 13, 2021 ORDER The application to reopen the claim for service connection for a right knee disability is granted. The application to reopen the claim for service connection for a left knee disability is granted. The application to reopen the claim for service connection for frostbite of the bilateral hands is granted. Entitlement to service connection for right knee arthritis is granted. Entitlement to service connection for left knee arthritis is granted. Entitlement to service connection for frostbite of the bilateral hands is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for bilateral numbness in the feet due to frostbite is denied. Entitlement to an evaluation in excess of 0 percent for bilateral hearing loss is denied. REMANDED Entitlement to service connection for a lower back condition secondary to the knees is remanded. Entitlement to service connection for a neck condition is remanded. Entitlement to service connection for hepatitis C stage IV is remanded. FINDINGS OF FACT 1. In an August 2012 rating decision, the Agency of Original Jurisdiction (AOJ) denied service connection for bilateral knee disabilities, and frostbite of the bilateral hands. 2. The notice of the August 2012 decision was properly promulgated, and no additional evidence was received, nor a notice of disagreement filed within one year of promulgation. 3. Evidence added to the record since the August 2012 rating decision is not cumulative or redundant of the evidence of record at the time of the decision and raises the possibility of substantiating the Veteran’s claim of entitlement to service connection for right knee arthritis. 4. Evidence added to the record since the August 2012 rating decision is not cumulative or redundant of the evidence of record at the time of the decision and raises the possibility of substantiating the Veteran’s claim of entitlement to service connection for left knee arthritis. 5. Evidence added to the record since the August 2012 rating decision is not cumulative or redundant of the evidence of record at the time of the decision and raises the possibility of substantiating the Veteran’s claim of entitlement to service connection for frostbite of the bilateral hands. 6. The Veteran’s right knee arthritis is at least as likely as not related to his in-service complaints and treatments of right knee pain. 7. The Veteran’s left knee arthritis is at least as likely as not related to his in-service complaints and treatments of left knee pain. 8. The Veteran has not had frostbite of the bilateral hands at any time during or proximate to the pendency of the claim. 9. The Veteran’s hypertension did not begin during active service and is not otherwise related to an in-service injury or disease. 10. The Veteran has not had bilateral numbness in his feet due to frostbite at any time during or proximate to the pendency of the claim. 11. The Veteran’s bilateral hearing has been manifested by hearing acuity of no worse than Level I in the right ear and no worse than Level I in the left ear. CONCLUSIONS OF LAW 1. The August 2012 rating decision that denied service connection for bilateral knee disabilities and frostbite of the bilateral hands is final. 38 U.S.C. § 7105(c) (2012) [2020]; 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2012) [2020]. 2. New and material evidence has been received to reopen the claims of entitlement to service connection for bilateral knee disabilities and frostbite of the bilateral hands. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for service connection for right knee arthritis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for left knee arthritis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for frostbite of the bilateral hands are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for bilateral numbness in the feet due to frostbite are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for a compensable rating for bilateral hearing loss are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from August 1973 to October 1976 and from December 1977 to October 1985. This case comes before the Board of Veterans’ Appeals (Board) on an appeal from a January 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office. In the Veteran’s January 2016 notice of disagreement, he included the issue of entitlement to special monthly compensation based on aid and attendance/housebound. The issue was then not included in the Form 9, Appeal to the Board of Veterans’ Appeals; therefore, the issue is not before the Board at this time. 1. New and material evidence having been received, the application to reopen the claim for service connection for a right knee disability is granted. 2. New and material evidence having been received, the application to reopen the claim for service connection for a left knee disability is granted. 3. New and material evidence having been received, the application to reopen the claim for service connection for frostbite of the bilateral hands is granted. In an August 2012 rating decision, the RO denied service connection for bilateral knee disabilities and frostbite of the bilateral hands. The Veteran was notified of the August 2012 rating decision and his procedural and appellate rights in a September 4, 2012, letter sent to his address of record and to his representative. He did not file a notice of disagreement within one year of notice of the August 2012 rating decision. No additional evidence was received within one year of notice of the August 2012 rating decision. For this reason, the August 2012 rating decision denial of service connection for bilateral knee disabilities and frostbite of the bilateral hands became final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. Generally, when a claim is disallowed, it may not be reopened and allowed, and a claim based on the same factual basis may not be considered. 38 U.S.C. § 7105(c). A claim on which there is a final decision may be reopened if new and material evidence is submitted. 38 U.S.C. § 5108. Evidence received since the August 2012 rating decision includes a private medical opinion from Dr. J.D. referable to the Veteran’s right and left knee disabilities. Such evidence provides a nexus opinion regarding the etiology of the Veteran’s bilateral knee disabilities. Thus, as service connection for his knee disabilities was previously denied on the basis that there was no evidence that the claimed conditions began or were caused by service and the newly received evidence addresses an unestablished factor of service connection, the Board finds that the evidence of record at the time of the decision and raises the possibility of substantiating the Veteran’s claim of entitlement to service connection for bilateral knee disabilities. The Veteran also claims service connection for frostbitten hands as secondary to his claimed bilateral knee disabilities. Having already found that new and material evidence exists sufficient to reopen the claim for bilateral knee disabilities, because this same evidence goes to the question of whether the Veteran may obtain service connection for a disability secondary to them, the Board concludes the same evidence is new and material for the claim for frostbitten hands. Accordingly, the Board concludes that the criteria for reopening service connection for bilateral knee disabilities and frostbite of the bilateral hands are met. 38 C.F.R. § 3.156(a). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated by service. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for a right knee disability. The Veteran seeks service connection for a right knee disability. The Veteran’s service treatment records have numerous complaints of right knee pain throughout service. He has complaints of right knee pain spanning from 1979 to 1985. A few of the complaints in service include: in August 1979, the examiner determined the Veteran suffered from bilateral chondromalacia patella; in January 1980, he complained of throbbing pain, feeling a clicking under his knee caps, falling due to his knees locking, and having pain with range of motion testing; in April 1982, he presented with knee pain due to a fall; in December 1982, he was diagnosed by an orthopedic doctor with patellofemoral pain; and in August 1985, the Veteran indicated that he had pain in his knees for the past six years. The Veteran underwent a VA examination in June 2012 for his right knee. The examiner diagnosed the Veteran with degenerative joint disease. The Veteran told the examiner that his knee pain began in 1979 and gradually got worse. The examination revealed he suffered from less movement than normal, had pain in his right knee, and that he suffered from flare-ups. The examiner, however, failed to opine as to the nature and etiology of the Veteran’s right knee condition. The Veteran underwent an x-ray in June 2012, and it revealed the Veteran suffered from mild osteoarthritis of the lateral compartment without acute fracture or dislocation of the right knee. In August 2012, an addendum opinion was associated with the file. The VA physician reviewed the record and mentioned the Veteran’s complaints in service of right knee pain. He then determined that the Veteran’s right knee arthritis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He concluded this based on there being no mention of a right knee condition on his separation examination in 1985, and no documentation of any medical, orthopedic, chiropractic, physical therapy diagnosis, or treatment for a right knee condition from 1985 to 2009. A private medical opinion was associated with the record in April 2020. The doctor examined the Veteran’s file and noted all complaints of right knee pain and treatment during service. He then opined that it was as likely as not that the current changes seen in the Veteran’s right knee were related to military service. He concluded it was related to service due to an injury during service then from wear and tear from his job during service. The Board finds both the VA and private medical opinions to be adequate and competent. Accordingly, the Board finds that the private medical opinion is at least as probative as the VA addendum opinion. The evidence is therefore at least in relative equipoise that the Veteran’s right knee arthritis are related to his in-service injury. As the evidence is in equipoise, the Board must grant the claim of entitlement to service connection for right knee arthritis. 38 C.F.R. § 3.102. 5. Entitlement to service connection for a left knee disability. The Veteran seeks service connection for his left knee arthritis. He contends his left knee disability is related to his complaints and treatments during service. The Veteran’s service treatment records have numerous complaints of left knee pain throughout service. He has complaints of left knee pain spanning from 1979 to 1985. A few of the complaints in service include: in October 1979, the examiner determined the Veteran suffered from a torn medial meniscus and bilateral chondromalacia patella; in January 1980 he complained of throbbing pain, feeling a clicking under his knee caps, falling due to his knees locking, and having pain with range of motion testing; in March 1980, the Veteran underwent arthroscopy of his left knee; in December 1982, he was diagnosed by an orthopedic doctor with bilateral patellofemoral pain; and in August 1985, the Veteran indicated that he had pain in his knees for the past six years. During the June 2012 VA examination for his knee pain, the examiner diagnosed the Veteran with left knee sprain. The Veteran told the examiner that his left knee pain began in 1979 and gradually got worse. The examination revealed he suffered from less movement than normal, had pain in his left knee, and that he suffered from flare-ups. The examiner, however, failed to opine as to the nature and etiology of the Veteran’s left knee condition. In the August 2012 addendum opinion, the physician determined that the Veteran’s left knee condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He concluded saying that the Veteran did suffer a left knee sprain in service, but there was no apparent treatment for the same for over twenty-four years after separation from service. A private medical opinion was associated with the record in April 2020. Dr. J.D. examined the Veteran’s file and noted all complaints of left knee pain and treatment during service. He then opined that since the Veteran had a left knee injury in service and was seen many times for bilateral knee pain, that it was at least as likely as not that the current changes seen in the Veteran’s left knee were related to military service. The Board finds both the VA and private medical opinions to be adequate and competent, and that the private medical opinion is at least as probative as the VA addendum opinion. The evidence is therefore at least in relative equipoise that the Veteran’s left knee arthritis is related to his in-service injury. As the evidence is in equipoise, the Board must grant the claim of entitlement to service connection for left knee arthritis. 38 C.F.R. § 3.102. 6. Entitlement to service connection for hypertension. The Veteran seeks service connection for his hypertension. In a January 2013 primary care note, the Veteran’s diagnosis for hypertension was confirmed. However, it was also noted he was diagnosed with hypertension five years prior, over twenty years after separation from service. The Veteran’s service treatment records are silent for any complaints, treatments, or diagnosis of hypertension. In a dental patient medical history, the record indicates the Veteran denied having high blood pressure in June 1981, June 1982, and again in March 1983. Also, the Veteran’s separation examination is silent for complaints, treatments, or diagnoses related to high blood pressure. Hypertension is a chronic disease for which certain presumptions of service connection are available. 38 C.F.R. § 3.303(b), 3.307(a), 3.309(a). However, these presumptions are available when the chronic disease is present during service or the year following separation from service. Id. The Veteran received a diagnosis for hypertension over twenty years after his separation from service. While he had reports of a few elevated blood pressure readings in service, the disability was not shown to be chronic in service, did not manifest to a compensable degree within a presumptive period, and as explained below, was not noted in service with attributable continuity of symptomatology. Therefore, the service connection on a presumptive basis is not warranted. Id. The Board then turns to direct service connection. The Veteran has not been provided with a VA medical examination and/or opinion regarding his hypertension; however, the Board finds that such is not necessary in the instant case. Specifically, as indicated previously, there is no competent evidence of an in-service injury and no indication that his hypertension may be related to service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). A mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide the claims. The Board finds the preponderance of the evidence is against a finding that the Veteran’s hypertension is related to service. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, the claim for hypertension must be denied. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.307, 3.309. 7. Entitlement to service connection for frostbite of the bilateral hands The Veteran seeks service connection for frostbite of the bilateral hands. That the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Pain that does not amount to a functional impairment of earning capacity is not considered a current disability under VA law and regulations. See Wait v. Wilkie, 33 Vet. App. 8, 15-16 (2020). The Veteran’s service treatment records are silent for frostbite during service. The Veteran has no complaints, treatments, or diagnoses of frostbite or bilateral hand disabilities during service. Consequently, the Board finds that the evidence of record does not reflect that the Veteran had the claimed condition. The Veteran’s representative argued that his bilateral hand condition was related to his neck and back conditions. April 2020 Brief. She suggests that the Veteran actually suffers from radiculopathy of his upper extremities, not numbness due to frostbite, and that his radiculopathy is caused by his neck and back conditions, which the Veteran contends are secondary to his knee disabilities. No evidence is referenced in the brief to support the assertion that the numbness is actually radiculopathy. However, the record shows no diagnosis of bilateral hand disabilities. There is no record of complaints, treatment, or diagnosis of numbness in his hands due to frostbite or radiating numbness due to his neck or lower back disabilities. There is one note in the record about the Veteran’s claim for frostbite bilateral hands. In a January 2013 primary care note, it says that the Veteran disclosed he had a claim in for bilateral hand frostbite, and that he cannot tolerate cold weather as it causes his hands to turn blue and numb. The Veteran has not been provided with a VA medical examination and/or opinion regarding his frostbite bilateral hands; however, the Board finds that such is not necessary in the instant case. Specifically, as indicated previously, there is no credible evidence of an in-service injury and no indication that his frostbite bilateral hands condition may be related to service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Additionally, a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide the claims. Therefore, based on the foregoing, the Board finds that service connection for frostbite of the bilateral hands is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection. As such, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 8. Entitlement to service connection for bilateral numbness in the feet due to frostbite. The Veteran seeks service connection for bilateral numbness in his feet due to frostbite. That the requirement of the existence of a current disability is satisfied when a claimant has a disability at the time he files his claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When the record contains a recent diagnosis of disability prior to a claimant filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Pain that does not amount to a functional impairment of earning capacity is not considered a current disability under VA law and regulations. Wait, 33 Vet. App. at 15-16. The Veteran’s service treatment records are silent for frostbite or numbness in his feet. The records show no complaints, treatment, or diagnosis of frostbite or numbness in his feet during or after service. Consequently, the Board finds that the evidence of record does not reflect that the Veteran had the claimed condition. In reaching this decision, the Board notes that the Veteran’s representative argued that his bilateral numbness in his feet was related to his neck and back conditions. She suggests that the Veteran actually suffers from radiculopathy of his lower extremities, not numbness due to frostbite, and that his radiculopathy is caused by his neck and back conditions, which the Veteran contends are secondary to his knee disabilities. The record reflects the Veteran complained of his lower back pain radiating down his back in December 2013, again in July 2014, and finally in September 2014. However, it is noted he does not have symptoms, and there is no indication or diagnosis that he suffers from numbness in his feet or from radiculopathy. The Veteran has not been provided with a VA medical examination and/or opinion regarding his bilateral numbness in his feet; however, the Board finds that such is not necessary in the instant case. Specifically, as indicated previously, there is no credible evidence of an in-service injury and no indication that his bilateral foot numbness may be related to service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Additionally, a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide the claims. Therefore, based on the foregoing, the Board finds that service connection for bilateral numbness in the feet due to frostbite is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection. As such, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 9. Entitlement to an evaluation in excess of 0 percent for bilateral hearing loss. The Veteran seeks a rating in excess of 0 percent for his service-connected bilateral hearing loss. He was granted service connection and a 0 percent disability rating in a January 2016 rating decision. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant’s favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found – a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. Ratings for hearing loss are determined in accordance with findings obtained on an audiometric examination. Hearing loss disability evaluations range from noncompensable (0 percent) to a maximum of 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests (Maryland CNC) in conjunction with the average hearing threshold, as measured by pure tone audiometric tests in the frequencies 1000, 2000, 3000, and 4000 cycles per second (Hertz). The rating schedule establishes eleven auditory acuity levels, designated from Level I for essentially normal hearing through Level XI for profound deafness. The assignment of disability ratings for hearing impairment is derived by a mechanical application of the Rating Schedule to the numeric designations assigned after audiometric evaluations are rendered. Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). The criteria for rating hearing impairment use controlled speech discrimination tests (Maryland CNC) together with the results of pure tone audiometry tests. These results are then charted on Table VI, or Table VIA in exceptional cases as described in 38 C.F.R. § 4.86, and Table VII, as set out in the Rating Schedule. 38 C.F.R. § 4.85. An exceptional pattern of hearing loss occurs when the pure tone threshold at 1000, 2000, 3000, and 4000 Hertz is 55 decibels or more, or when the pure tone threshold is 30 decibels or less at 1000 Hertz and 70 decibels or more at 2000 Hertz. 38 C.F.R. § 4.86. The Veteran underwent a VA hearing loss examination in January 2016. The pure tone thresholds in decibels at the tested frequencies of 1000, 2000, 3000, and 4000 Hertz were 40, 50, 40, and 45, respectively, in the right ear and 35, 40, 40, and 35, respectively, in the left ear. No exceptional pattern of hearing loss was shown. The examiner noted that the pure tone threshold average in the right ear was 44 decibels and the average in the left ear was 38 decibels. Speech discrimination, using the Maryland CNC, was 96 percent in the right ear and 94 percent in the left ear. The foregoing audiometry test results equate to Level I hearing in the right ear and Level I in the left ear pursuant to Table VI. Applying the percentage ratings for hearing impairment found in Table VII, Level I hearing in one ear and Level I hearing in the other ear results in a 0 percent rating. Based on the foregoing, the Board finds the VA examinations competent and more probative and that the preponderance of the evidence is against the claim for an increased rating in excess of 0 percent. In reaching such determination, the Board considered the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the Veteran’s claim, such doctrine is not applicable, and it must be denied. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for lower back condition secondary to knees is remanded. The Veteran appeals his claim for lower back condition as secondary to his bilateral knee condition. In order for the Veteran to establish service connection on a secondary basis, it requires evidence sufficient to show (1) that a current disability exists, and (2) that the current disability was either (a) proximately caused by or (b) aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310. The Veteran was previously denied service connection and an examination for his back condition because he did not meet the requirement of having a service-connected disability that proximately caused or aggravated his back condition. However, as of this order, the Veteran is now service connected for his bilateral knee conditions. The Veteran is now entitled to an examination to determine if his lower back condition is secondarily related to his now service-connected bilateral knee disabilities. Therefore, a remand for an examination and an opinion addressing whether his lower back condition is proximately due to or caused by his service-connected knee disabilities is necessary. 2. Entitlement to service connection for neck condition is remanded. The Veteran appeals his denial of service connection for his neck condition. A February 2013 x-ray confirmed the Veteran was diagnosed with cervical spine degenerative disc disease at C5-6 and C6-7, located in his lower neck. While the Veteran’s service treatment records are silent for any neck conditions during service, the Veteran, through his representative, suggests his neck condition is secondary to his bilateral knee disabilities. As stated above, the Veteran’s now service-connected knee disabilities provide the primary disability for a secondary claim. Therefore, a remand is necessary to determine the nature and etiology of the Veteran’s neck disability as well as whether his neck condition is proximately due to or caused by his service-connected knee disabilities. 3. Entitlement to service connection for hepatitis C stage IV is remanded. The Veteran appeals his denial of service connection for hepatitis C. The Veteran was diagnosed with hepatitis C in January 2013. He informed the examiner that in 1979 his wife had been diagnosed with hepatitis with jaundice, but he was tested and did not have it. He indicated he had air gun vaccines during service, and he donated blood from 1973 to 1985. In November 2016, the Veteran returned a questionnaire for hepatitis risk factors. He indicated that he had none of the common risk factors associated with hepatitis exposure and maintains his only risk factor he had for exposure to hepatitis C was his being a Vietnam era veteran. Therefore, a remand is necessary for a medical opinion concerning the nature and etiology of the Veteran’s hepatitis C. The matters are REMANDED for the following actions: 1. Associate with the claims folder updated treatment records. 2. Obtain an addendum opinion from the appropriate clinician to determine the nature and etiology of the Veteran’s lower back condition. The examiner is asked to provide a response to whether the Veteran’s lower back condition is at least as likely as not (1) proximately due to, or (2) aggravated beyond its natural progression by his service-connected bilateral knee disabilities. Aggravation means an increase in disability – any additional impairment of earning capacity – of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. 3. Obtain an addendum opinion from the appropriate clinician to determine the nature and etiology of the Veteran’s neck condition. The examiner is asked to provide responses to the following: (a). Whether it is at least as likely as not (50 percent or greater probability) that such had onset in, or is otherwise related to, the Veteran’s period of active duty service. (b). Whether the Veteran’s neck disability is at least as likely as not (1) proximately due to, or (2) aggravated beyond its natural progression by his service-connected bilateral knee disabilities. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. 4. Obtain an addendum opinion from the appropriate clinician to determine the nature and etiology of the Veteran’s hepatitis C. The examiner is asked to consider the Veteran’s responses to his risk factors for hepatitis questionnaire and his contentions of exposure due to air gun vaccines. The examiner should determine whether it is at least as likely as not (50 percent or greater probability) that such had onset in, or is otherwise related to, the Veteran’s period of active duty service. 5. All examiners must review the entire claims folders, including a copy of this remand. If the examiner finds an examination is necessary, then schedule the examination. A complete rationale must be provided for all opinions expressed. If the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion would be speculative. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Doerfler, Associate 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.