Citation Nr: 21021982 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 15-15 316 DATE: April 14, 2021 ORDER 1. Entitlement to service connection for lumbar degenerative disc disease (low back condition) is denied. 2. Entitlement to service connection for post-traumatic stress disorder (PTSD) is denied. 3. Entitlement to service connection for headaches is denied. REMAND 1. Entitlement to service connection for chronic fatigue syndrome is remanded. 2. Entitlement to service connection for chronic sinusitis (claimed as sinus condition) is remanded. 3. Entitlement to service connection for dermatitis is remanded. 4. Entitlement to service connection for chronic cholelithiasis (gall bladder removal) is remanded. 5. Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. The weight of competent and credible evidence is that the Veteran’s low back disorder did not manifest during or within one year of active duty and is not caused by any aspect of active duty. 2. The weight of competent and credible evidence of record does not show a current diagnosis of PTSD or any other psychiatric disorder. 3. The weight of competent and credible evidence is that the Veteran’s headache disorder did not manifest during or within one year of active duty and is not caused by any aspect of active duty or caused or aggravated by service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back condition are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 2. The criteria for service connection for PTSD are not met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304(f)(5) (2020). 3. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Marine Corps from February 1987 to October 1991. He was awarded the Combat Action Ribbon for service during the Persian Gulf War. These matters come before the Board of Veterans’ Appeals (Board) from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO) dated in September 2013, May 2014, and March 2015. In February 2020 the Board issued a remand order with instructions for further development. The Board finds that there has been substantial compliance with the Board’s remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Generally, service connection may be granted for any disability resulting from injury suffered or disease contracted in line of duty, or for aggravation in service of a pre-existing injury or disease. 38U.S.C. §§1110, 1131. Service connection may be established by demonstrating that the disability was first manifested during service and has continued since service to the present time or by showing that a disability which pre-existed service was aggravated during service. Service connection may be granted for any disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38C.F.R. §3.303. 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-nexus-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). Establishing service connection on a secondary basis 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. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310 (a)-(b) (2016). Service connection for certain chronic diseases, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). In such cases, the disease is legally presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307 (a). To establish service connection for a chronic disease under this provision, there must be: evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307 ), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303 (b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Subject to various conditions, service connection may be granted for a disability due to undiagnosed illness of a veteran who served in the Southwest Asia Theater of operations during the Persian Gulf War. Among the requirements are that there are objective indications of a chronic disability resulting from an illness or combination of illnesses manifested by one or more signs or symptoms such as fatigue, signs or symptoms involving the skin, headache, muscle pain, joint pain, neurological signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper and lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. The illness must become manifest during either active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more, under the appropriate diagnostic code of 38 C.F.R. Part 4, not later than December 31, 2021. By history, physical examination, and laboratory tests, the disability cannot be attributed to any known clinical diagnosis. There must be objective signs that are perceptible to an examining physician and other non-medical indicators that are capable of independent verification. There must be a minimum of a six-month period of chronicity. There must be no affirmative evidence that relates the undiagnosed illness to a cause other than being in the Southwest Asia Theater of operations during the Persian Gulf War. 38 U.S.C. § 1117 (2012); 38 C.F.R. § 3.317 (2020). If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98 (Aug. 3, 1998). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). For purposes of this section, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a 6- month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Entitlement to service connection for lumbar degenerative disc disease (claimed as lower back pain) The Veteran contends that his back disorder is due to his military service. The file of service treatment records is partially legible. A review of the Veteran’s STRs shows that the Veteran sought treatment in May 1991 for a strain of the left shoulder after heavy lifting. He also received treatment at various times for hip, arm, knee and chest pain. However, in the June 1991 discharge examination, the Veteran denied any recurrent back pain and the examiner did not note any spinal abnormalities. In May 2012 the Veteran submitted a claim of service connection for lower back pain, and in September 2013 was provided a VA examination. The Veteran reported that when he was deployed in Saudi Arabia and Kuwait from 1990-1991, he routinely carried a 40 to 70 pound pack upon his back and that his lumbar spine pain began during that time. The Veteran reported persistent pain to the present, with brief episodes of pain with burning character radiating from left leg and foot, with the pain changing to numbness. The examiner noted a diagnosis of lumbar spine degenerative disc disease, with the date of diagnosis being 1990-1991, apparently based on the Veteran’s reports as there was no supporting evidence of this diagnosis in the file. See August 2013 CAPRI, pp. 12-14. A medical opinion was provided by a VA examiner in September 2013. The examiner found that it was less likely than not that the Veteran’s back pain was due to his military service, stating: “The veteran was evaluated on one occasion for low back strain in 5/91 after lifting. No further complaints of back pain or evaluations for back pain were found in the military medical records. Separation Med Exam does not mention back condition. The veteran would not develop chronic back pain from one episode of strain from lifting in 1991. Not related to military service.” See September 2013 CAPRI, p. 6. The Board’s review of this May 1991 STR entry is that the Veteran reported shoulder and not lower back pain. The Veteran’s claim was subsequently denied in September 2013 and the Veteran submitted a timely Notice of Disagreement (NOD) in September 2013. No further evidence was provided by the Veteran, and a March 2015 Statement of the Case (SOC) explained the reasons for the denial. The Veteran submitted a timely VA Form 9 in May 2015. The Board included the Veteran’s back condition in its February 2020 remand orders, but did not include any analysis for the condition, nor was any development ordered. As such, in the Veteran’s November 2020 Supplemental Statement of the Case (SSOC), the denial was explained and no further development was conducted. The Veteran has been diagnosed with a back condition during the appellate period, and as such the first element of service connection has been met. Furthermore, the Veteran has referenced an in-service event as being the cause of his back condition, which meets the criteria of the second element of service connection. However, the third element of service connection, a nexus between the Veteran’s current disability and his military service, has not been met. In reaching this conclusion, the Board acknowledges that the Veteran believes that his current back condition was caused by his military service. The Board has considered the Veteran’s lay statements. However, the Veteran is not shown to possess the requisite medical training or expertise to provide a competent opinion regarding the etiology of his disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). The Board assigns less credible weight to the report of continuous back pain since the lifting event in 1991 because the Veteran denied recurrent back pain during the discharge physical examination. The Board assigns significant probative value to the findings of the September 2013 VA examiner, as the examiner reviewed the Veteran’s medical records, considered his lay statements and provided a rationale based upon the record. Absent a competent and positive nexus opinion, service connection for a low back condition may not be granted. The Board has considered the applicability of the benefit of the doubt doctrine. As the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Entitlement to service connection for PTSD In May 2012 the Veteran the Veteran submitted a claim of service connection for PTSD, which the Board accepts as also being a claim of service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The first element of service connection is a current disability. The Board finds that the claim must be denied as this element has not been met. A review of the records shows that the Veteran’s STRs are absent complaint, treatment or diagnosis for a mental health disorder. Post-service, in October 2013 the Veteran was found to not have depression or PTSD via a PHQ-2 Screen and a PTSD 4Q screening. See May 2014 CAPRI, pp. 13-14. In October 2014 the Veteran was found to possibly have PTSD “based on his job description.” In November 2014 the Veteran underwent a PTSD screening which showed that the Veteran was ‘moderate’ when it came to being jump or easily startled and for being on alert, and was found to be “a little bit” when it came to being unable to remember important parts of his stressful experiences and avoiding feelings related to his in-service stressors. The Veteran indicated “not at all” for being irritable or having angry outbursts, as well as for feeling distant from others, not having interest in activities that he used to enjoy or being emotionally numb. See April 2020 CAPRI, pp. 187, 191. Subsequently, the record does not show any complaint, treatment or diagnosis of a mental health condition. To the contrary, the Veteran denied any psychiatric conditions, to include depression or anxiety, in August 2016, June 2017, September 2018 and October 2019 the Veteran denied any psychiatric history as well as any current depression or anxiety. Id at 18, 46, 89, 134. The Veteran submitted a claim of service connection in May 2012. A VA examination was provided, however the examiner conducted it under the mistaken impression that the Veteran had not seen combat. As such, the Board found that the examination was inadequate, and in February 2020 the Board issued a remand ordering a VA examination to determine the etiology of the Veteran’s claimed PTSD. As per the Board’s remand instructions, a VA examination was provided in November 2020. There, the VA examiner did not diagnose the Veteran with PTSD or any other mental disorder. At the examination the Veteran stated that “he saw [a] mental health [provider] in 1997 because when you get hired at his job, he had a psychiatric evaluation and as per vet, no diagnosis made and was cleared to work. No psychiatric medications, no psychiatric hospitalizations, no suicide attempts.” The Veteran described his symptoms as being “paranoia”, which began with the fear that someone would break into his home but has improved to the point where “he feels like he has to check the stove before leaves the house.” The Veteran further stated that he felt like he was being watched when in public, that he was always on edge, was easily irritated, didn’t like heights and didn’t have a desire to be with friends or go to parties. Socially, the Veteran described himself as having a good relationship with his wife of 32 years and his 2 children, with his hobbies including walking, jogging, and going out to the park and beach with his family. The Veteran did not indicate any issues with his career, stating that he had worked as a correctional police officer for the past 24 years and did “good quality work” without any problems. The VA examiner opined: Although pt (patient) does have military service in a combat area, and his experience seeing dead bodies in Iraq does qualify as a Criteria A trauma, pt’s symptoms do not meet DSM-Criteria for PTSD. Additionally, review of medical records in VBMS indicates: On JUN 16, 2017 during a clinic visit, pt denied psychiatric symptoms or history. On 9-27-2018 during a clinic visit, pt denied psychiatric symptoms or history. PTSD screening score in clinic was 2: Negative. On 10-24-2019 during a clinic visit, pt denied psychiatric symptoms or history.” See November 2020 C&P Exam. The Board finds that the November 2020 VA examiner’s opinion is of significant probative value, given that the VA examiner conducted an in-person examination, reviewed the Veteran’s medical records, considered the Veteran’s lay statements and provided a rationale based upon the record. Following this examination and the subsequent denial of benefits, the Veteran wrote to the Board and stated that he continues to have flashbacks and memories that he copes with every day. See November 2020 Correspondence, p. 2. In reaching this conclusion, the Board acknowledges the Veteran’s lay statements regarding feelings of paranoia and being easily irritated. However, these statements stand in contrast with the Veteran’s repeated denials of having any psychiatric symptoms throughout the appellate period and with the Veteran only reporting psychiatric symptoms at his examination for service connection. Given these inconsistencies, the Board finds the medical opinion of the November 2020 VA examiner to be of more probative value than the inconsistent lay statements of the Veteran. In sum, the Board has considered both the medical and lay evidence; although the Veteran asserts service connection is warranted, as summarized above, the Veteran’s own statements (as recorded in treatment records) deny such symptoms, aside from a single instance of the Veteran stating that he was at a “moderate” level for being always at alert and being startled. Without a current diagnosis, the Veteran’s service connection claim for a psychiatric condition must be denied. See 38 C.F.R. §§ 3.102, 3.303; see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (existence of a current disability is the cornerstone of a claim for VA disability compensation). Entitlement to service connection for headaches The Veteran contends that his headaches are caused by, or are aggravated by, his service-connected tinnitus. See July 2015 Form 9. The Board has accepted this claim as being secondary to not only the Veteran’s service connected tinnitus, but also his other service connected disabilities. A review of the Veteran’s STRs do not show any complaint, treatment or diagnosis for a headache condition. Given that neither the record, nor the Veteran’s statements, indicate direct service connection, the Board’s analysis focuses on the Veteran’s contention for secondary service connection. The first indication of headaches appearing in the Veteran’s medical treatment records came in August 2013 in a pulmonary sleep study consultation, in which the Veteran reported morning headaches. See May 2014 CAPRI, p. 2. The Veteran repeated this at a January 2014 at a pulmonary sleep consultation, in which the Veteran stated that “sometimes he feels has a headache in the morning. He thinks it is from his sinuses.” Id at 1. Then, the Veteran reported headaches at his Gulf War Registry exam in July 2014. The record does not contain any further complaints, treatment or diagnosis for headaches. The Veteran submitted his claim of service connection for headaches in November 2013 and the claim was denied without an examination. In February 2020 the Board issued remand orders for a VA examiner to provide a nexus opinion regarding secondary service connection. As per Board remand instructions, a nexus opinion was provided in July 2020. There, the VA examiner opined that the Veteran’s headaches are less likely than not proximately due to or the result of the Veteran’s service connected conditions. The examiner stated: Chronic headaches was reported in a Gulf War Registry exam from July 23 2014. Other than that, his treatment medical records are silent for a chronic headache condition or a diagnosed headache condition. There is no objective documentation from a treating medical provider that has further substantiated this headache condition or has shown any potential link/connection between his reported headaches and any of his service connected conditions or his claimed sinusitis, PTSD, and chronic fatigue syndrome, or the combination thereof. Therefore, his claimed headaches, in my opinion, would be less likely than not proximately due to or the result of any of his service connected conditions. See July 2020 C&P Exam, p. 2. The Board affords significant probative weight to the findings of the July 2020 VA examiner, as the examiner reviewed the Veteran’s medical records, considered his lay statements and provided a rationale based upon the record. A careful review of the record has not uncovered any positive nexus opinions. In the absence of a positive nexus opinion, the third element of service connection has not been met and as such service connection for the Veteran’s headaches may not be granted. In reaching this conclusion, the Board acknowledges that the Veteran believes that his current headaches were caused by his service-connected disabilities. The Board has considered the Veteran’s lay statements. However, the Veteran is not shown to possess the requisite medical training or expertise to provide a competent opinion regarding the etiology of his disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). The Board has considered the applicability of the benefit of the doubt doctrine. As the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND Entitlement to service connection for chronic fatigue syndrome The Veteran contends that he suffers from chronic fatigue syndrome, directly due to environmental hazards in the Gulf War, and secondary to his service-connected fibromyalgia and sleep apnea. See November 2020 Correspondence. The first element of service connection is a current disability. In February 2020 the Board issued remand orders for further development, having found that while the Veteran suffered from chronic fatigue syndrome, it was not clear whether the disability was medically attributable to his service-connected sleep apnea. See February 2020 BVA Decision. The evaluation of the same manifestation under different diagnoses, known as pyramiding, is to be avoided. See 38 C.F.R. § 4.14 ; Esteban v. Brown, 6 Vet. App. 259 (1994). When a Veteran has separate and distinct manifestations from the same injury he or she should be compensated under different Diagnostic Codes. When it is not possible to separate the effects of the service-connected disability from a non-service-connected disability, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102 ; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). On the other hand, secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In the present case, fatigue has been attributed to the Veteran’s sleep apnea. See October 2019 Medical Treatment Record – Non – Government Facility. In an August 2013 VA Gulf War examination, the examiner found that the Veteran did not have chronic fatigue syndrome but rather obstructive sleep apnea. However, an August 2020 clinical note stated that the Veteran’s fibromyalgia could also be contributing to the Veteran’s fatigue, but that the Veteran’s fatigue was of unclear etiology. See October 2020 CAPRI, pp. 4-6. The Board finds the record to remain unclear as to whether the Veteran’s chronic fatigue syndrome is part of an already service-connected disability, or whether it is a separate condition that is aggravated by a service-connected disability. As the Board may not make medical determinations, an adequate medical opinion is necessary to address this issue. Entitlement to service connection for chronic sinusitis The Veteran contends that he has sinusitis due to his military service. Specifically, the Veteran has recounted having a runny nose, coughing, shortness of breath, as well as irritation to his breathing, eyes, nose and throat from inhaling clouds of soot, liquid, aerosols and gases while deployed in the Gulf. See November 2020. In May 2012 the Veteran submitted a claim of service connection for chronic sinusitis. In August 2013 a VA examination was provided. There, the examiner acknowledged that in 1989 the Veteran developed episodes of sinusitis and diagnosed the Veteran with sinusitis. See August 2013 CAPRI, p. 26. Based upon the above, the Board finds that the Veteran’s claim has met the burdens of the first and second elements of service connection, as a disability diagnosed during the appellate period had been shown, and the Veteran had pointed to an in-service event or injury. Therefore, the Board’s analysis must focus on the third element of service connection, a medical nexus between the Veteran’s current disability and his military service. As explained above, this is a finding that neither the Veteran, nor the Board, may make. As such, the Board turns to the medical evidence of record. In September 2013 the examiner opined that the Veteran’s respiratory conditions were not service connected as they are not presumptive conditions. See September 2013 CAPRI, p. 5. The Board finds this rationale to be insufficient, as lacking presumptive service connection does not preclude claims of direct service connection. A review of the Veteran’s medical records shows continual complaints and treatments for both sinusitis and rhinitis throughout the appellate period. However, the Veteran’s medical records do not contain any nexus opinions. And while the Veteran’s claim of service connection for sinusitis was remanded by the Board in February 2020, the Board did not explicitly request an addendum opinion regarding the etiology of the Veteran’s sinusitis. While the Board regrets the additional delay, it is found that an addendum opinion is required, given that a probative nexus opinion is not of record. Entitlement to service connection for dermatitis The Veteran contends that his dermatitis is caused by exposure to environmental hazards in the Gulf War. See November 2020 Correspondence, p. 2. A review of the Veteran’s STRs shows an entry with an illegible date that indicated a diagnosis of contact dermatitis. The entry did not state where the dermatitis was located. See December 2013 STR-Medical, p. 54. Post service, the first instance of dermatitis in the record came in an October 2013 medical note, in which the Veteran was prescribed medication for eczematous dermatitis. See May 2014 CAPRI, p. 9. In November 2014 the Veteran submitted a claim of service connection for his dermatitis. A VA examination was provided in February 2015. There, the Veteran stated that his dermatitis began in 1992, characterized by “cracking feet with bleeding”, which then moved to his hands and had a “whole body” scratching sensation. At the examination, the Veteran was diagnosed with dermatitis. The VA examiner remarked “both conditions have a clear diagnosis and etiology. Given the symptom timing (a full two years after potential exposure, it is less likely than not that these conditions are related to a specific exposure event during service in SWA.” See February 2015 C&P Exam. The Veteran’s claim was subsequently denied, and the Veteran submitted a timely NOD and VA Form 9. In February 2020, the Board issued a remand order, in which it was found that the February 2015 VA examination’s remarks did not constitute a nexus opinion. As such, an addendum opinion was ordered. As per Board remand instructions, an addendum opinion was provided in October 2020. There, the VA examiner opined that it was less likely than not that the Veteran’s dermatitis was caused by his military service. The VA examiner stated that the contact dermatitis found in the Veteran’s STRs did not include any indication to assign to any part of the body or any other details, and as such “that entry is clearly not sufficient enough to be able to determine what this is in reference to or which body area this was in reference to or what the context or circumstance of this rash was.” The VA examiner concluded that “I am unable to make any plausible or reasonable connection/relationship between that undated and limited STR entry referenced above and the C&P Skin exam from February 5, 2015 where dermatitis and tinea pedis were diagnosed. As such, the dermatitis and tinea pedis that were diagnosed on Feb 5 2015 is less likely than not related to, caused by, or incurred by “A: contact dermatitis” in his STR where there were no further details documented in that STR entry to further characterize the context of that “contact dermatitis.” See October 2020 C&P Exam. The Board finds the October 2020 VA examiner’s nexus opinion to be of some probative value, as the VA examiner reviewed the Veteran’s records, considered his lay statements and provided a rationale supported by the record. However, after the Veteran’s denial was confirmed by the RO, in response the Veteran submitted a statement in which he raised the contention of secondary service connection, raising the theory that his dermatitis was caused or aggravated by his service-connected asthma, rhinitis and/or fibromyalgia. See November 2020 Correspondence, p. 2. McLendon v. Nicholson, 20 Vet. App. 79 (2006), sets a low bar to afford an examination for a claimed service-connected condition. As there is an indication that the Veteran’s dermatitis may have been caused or aggravated by a service-connected disability, an examination must be afforded upon remand. See id. at 82-3 Entitlement to service connection for chronic cholelithiasis (gall bladder removal) Entitlement to service connection for gastro-esophageal reflux disease (GERD) The Veteran contends that his gall bladder disease and GERD is due to the environmental hazards that he was exposed to in the Gulf War and that the disease is secondary to his irritable bowel syndrome. See November 2020 Correspondence. In September 2013 a VA examination was provided in which the VA examiner provided a nexus opinion regarding direct service connection. However, the issue of secondary service connection has been raised. A review of the record does not show any nexus opinions regarding the contention of secondary service connection. As above, the issue of the Veteran’s gall bladder disease and GERD was remanded by the Board in February 2020, but was done so without remand instruction. Under McLendon the bar is low for an examination to be provided in service-connection claims. The Board finds that in the present case, as there is a possibility that the Veteran’s service-connected irritable bowel syndrome may aggravate the Veteran’s gall bladder disease, a remand is required. Regarding GERD, the Veteran was likewise provided a nexus opinion in September 2013. However, the examiner merely stated that the Veteran did not have GERD while on active duty and that the disease is not presumptive. The Board finds this nexus opinion to be conclusory and without the requisite detail needed for the Board to reach a decision. Given that the September 2013 nexus opinion was inadequate for adjudication, and as the Veteran raised the issue of secondary service connection, a remand is required. These matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s chronic fatigue syndrome, and whether it is as likely as not (at least 50 percent) by any of the Veteran’s service-connected disabilities. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s chronic sinusitis, and whether it is as likely as not (at least 50 percent) caused by the Veteran’s military service, and whether it is at least as likely as not (50 percent) that the Veteran’s condition was either caused by, or aggravated by any of the Veteran’s service-connected disabilities. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s currently shown dermatitis is as likely as not (at least 50 percent) caused by, or aggravated by, any of the Veteran’s service-connected disabilities. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s current gall bladder disease is as likely as not (at least 50 percent) caused by, or aggravated by, any of the Veteran’s service-connected disabilities. 5. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s current GERD is as likely as not (at least 50 percent) caused by his military service, and whether it was caused by, or aggravated by, any of the Veteran’s service-connected disabilities. If the examiner(s) are unable to provide any of the required opinions, he or she should explain why. If the examiner(s) cannot provide an opinion without resorting to mere speculation, he or she should indicate if the inability to provide an opinion was due to the limits of the examiner’s knowledge, the limits of medical knowledge in general, or if there was additional evidence that, if obtained, would permit the opinion to be provided. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Abels, 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.