Citation Nr: 21022235 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 15-44 162 DATE: April 15, 2021 ORDER Entitlement to a rating in excess of 10 percent prior to January 1, 2020 (with exception for a 13-month period in which a total rating was awarded), and in excess of 30 percent from January 1, 2020, for status post total right knee replacement (previously rated as arthritis of the right knee) is dismissed. The application to reopen a claim of entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. The application to reopen a claim of entitlement to service connection for left knee disorder is granted. Entitlement to service connection for right shoulder injury is dismissed. Entitlement to service connection for PTSD is denied. Entitlement to service connection for major depressive disorder is granted. Entitlement to service connection for tinnitus is granted. REMANDED Entitlement to service connection for a left knee disorder is remanded. FINDINGS OF FACT 1. In February 2021, prior to the issuance of a decision on the appeal, the Veteran stated on the record at a Board hearing that he wished to withdraw his appeal as to the issue of entitlement to an increased rating for his service-connected right knee. 2. A March 2010 rating decision denied entitlement to service connection for PTSD. The Veteran did not timely appeal the decision nor submit new and material evidence within one year of notification of the decision. 3. Evidence received since the March 2010 rating decision that denied service connection for PTSD relates to a previously unestablished fact necessary to substantiate the claim. 4. A November 2009 rating decision denied entitlement to service connection for left knee condition. The Veteran did not timely appeal the decision nor submit new and material evidence within one year of notification of the decision. 5. Evidence received since the November 2009 rating decision that denied service connection for left knee condition relates to a previously unestablished fact necessary to substantiate the claim. 6. In February 2021, prior to the issuance of a decision on the appeal, the Veteran stated on the record at a Board hearing that he wished to withdraw his appeal as to the issue of entitlement to service connection for a right shoulder disorder. 7. There is no credible supporting evidence of an in-service PTSD stressor. 8. The Veteran’s major depressive disorder is attributable to service. 9. The Veteran’s tinnitus had its onset during active service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of entitlement to a rating in excess of 10 percent prior to January 1, 2020 (with exception for a 13-month period in which a total rating was awarded), and in excess of 30 percent from January 1, 2020, for status post total knee replacement (previously rated as arthritis of the right knee) are met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 2. The March 2010 rating decision that denied service connection for PTSD is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 3. Evidence received since the March 2010 rating decision that denied service connection for PTSD is new and material, and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 4. The November 2009 rating decision that denied service connection for left knee condition is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 5. Evidence received since the November 2009 rating decision that denied service connection for left knee condition is new and material, and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 6. The criteria for withdrawal of entitlement to service connection for right shoulder injury are met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 7. The criteria for service connection for PTSD are not met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304, 4.125. 8. The criteria for service connection for major depressive disorder are met. 38 U.S.C. §§ 1110; 38 C.F.R. §§ 3.303, 3.304, 4.125. 9. The criteria for service connection for tinnitus are met. 38 U.S.C. § 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1993 to December 1995. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of November 2012. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ) in February 2021. A transcript of the hearing is of record. The Board may dismiss any appeal that fails to allege a specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105; 38 C.F.R. § 20.202. An appeal may be withdrawn as to any issue involved in the appeal at any time before the Board promulgates a decision. Withdrawal may be made by the appellant or an authorized representative. A withdrawal is effective upon receipt. The withdrawal of an appeal on the record at a hearing need not be in writing. 38 C.F.R. § 20.204. Increased Rating 1. Entitlement to a rating in excess of 10 percent prior to January 1, 2020 (with exception for a 13-month period in which a total rating was awarded), and in excess of 30 percent from January 1, 2020. Following the Veteran’s service-connection claim of January 1996, a rating decision of September 1996 granted service connection for right knee strain, with a 10-percent evaluation, effective December 21, 1995. In July 2002, the Veteran filed a claim for rating increase. A rating decision of May 2003 decreased the evaluation of chondromalacia patella, right knee (previously rated as right knee strain) from 10 percent to 0 percent, effective August 1, 2003. A rating decision of November 2009 increased the rating for right knee chondromalacia patella to 10 percent, effective May 20, 2009. In August 2012, the Veteran filed a claim for rating increase, which was denied by a rating decision of November 2012. The Veteran filed a notice of disagreement (NOD) in January 2013 and VA Form 9 in October 2015. A rating decision of March 2019 increased the rating to 100 percent for the period of November 20, 2018 to January 1, 2020, based on a total right knee replacement of November 20, 2018. A 30-percent evaluation was assigned from January 1, 2020, for status post total knee replacement (previously rated as arthritis of the right knee). In February 2021, the Veteran stated on the record that he wished to withdraw his appeal as to entitlement to an increased rating for his service-connected right knee disability. Because he has withdrawn the appeal, there remains no allegation of an error of fact or law for appellate consideration. The Board does not have jurisdiction to review the appeal, and it will be dismissed. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.202, 20.204. Requests to Reopen Claim Generally, a claim that has been denied in a final, unappealed rating decision may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c). An exception provides that VA shall reopen a disallowed claim if new and material evidence is presented or secured with respect to the claim. 38 U.S.C. § 5108. VA will generally presume the credibility of the evidence in determining whether it is new and material. See Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The threshold for determining whether new and material evidence has been submitted is low. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). The claimant will be given the benefit of the doubt as to any issue material to the determination of a matter when there is an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for PTSD. In July 2002, the Veteran filed a service-connection claim for “personality disorder, depression, suicidal, chronic disorder, [and] anti-social personality disorder.” A rating decision of February 2003 denied entitlement to service connection for adjustment disorder and alcohol dependence (also claimed as depression and personality disorder). In January 2010, the Veteran filed a service-connection claim for PTSD and for “bipolar depression.” A rating decision of March 2010 denied service connection for PTSD. Entitlement to service connection for bipolar depression was also denied on the basis that no new and material evidence had been received. The basis for the denial of service connection for PTSD was that an in-service stressor could not be verified. The Veteran did not timely appeal the rating decision nor submit new and material evidence within one year of notification of the decision, which became final. 8 U.S.C. § 7105; 38 C.F.R. § 20.1103. In August 2012, the Veteran filed a service-connection claim for PTSD. A rating decision of November 2012 denied the claim on the basis that new and material evidence had not been received since the denial of March 2010. The Veteran filed a NOD in January 2013 and VA Form 9 in October 2015. New evidence has been received since January 2010 rating decision. A VA treatment record of July 2013, which diagnosed PTSD, notes the Veteran’s report of having seen his drill instructor commit suicide and having experienced psychiatric symptoms during service as a result. The latter evidence was not of record at the time of the last final denial of the claim. Presumed to be credible for purposes of reopening, the new evidence is also material to the claim, because it relates to the previously unestablished element of an in-service stressor. Previously, the Veteran had alleged two other incidents as in-service stressors that caused his PTSD. Thus, the new evidence is not cumulative or redundant of the evidence of record at the time of the prior final denial. Material evidence can be evidence that contributes to a more complete picture of the circumstances surrounding the origin of the claimed injury or disability. See Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). Because new and material evidence has been received, the claim of entitlement to service connection for PTSD will be reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). The Board notes that service personnel records were added to the claims file in January 2014 that were in existence, but not associated with the claims file, at the time of the prior denial of the claim in March 2010. The records are not “relevant” to the claim in that they do relate to the unestablished element of the claim: credible supporting evidence that the claimed in-service stressor occurred. Had these official service department records been relevant to the PTSD claim, VA would reconsider the claim without requiring the receipt of new and material evidence. 38 U.S.C. § 3.156(c)(1); see also Kisor v. Wilkie, No. 2016-1929, 2020 U.S. App. LEXIS 25527 (Fed. Cir. Aug. 12, 2020). 3. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for a left knee disorder. In January 1996, the Veteran filed a service-connection claim for injury to the right knee. A rating decision of September 1996 granted service connection for right knee strain, with a 10-percent evaluation, effective December 21, 1995. A July 2002 filing of the Veteran, which stated, in part, that he was filing for service connection for chronic knee pain, was construed by the agency of original jurisdiction (AOJ) as a claim for rating increase concerning the right knee disability. An August 2009 statement of the Veteran (“I still have problems with my knees when I do exercise walking”) was construed as a service-connection claim for a left knee disorder. A rating decision of November 2009 denied entitlement to service connection for left knee condition. In August 2012, the Veteran filed a service-connection claim for a left knee condition as due to his service-connected right knee condition. A rating decision of November 2012 denied service connection for degenerative joint disease, left knee (claimed as left knee condition). The claim, being considered on the merits, was implicitly reopened. The Veteran filed a NOD in January 2013 and VA Form 9 in October 2015. Regardless of the fact that the Veteran now advances a new theory of service connection based on secondary causation or aggravation by a service-connected disability, the August 2012 claim is an application to reopen the previously denied claim. See Roebuck v. Nicholson¸ 20 Vet. App. 307, 313 (2007). New evidence has been received since the November 2009 rating decision. The Veteran testified before the Board in in February 2021 that he was told by a VA doctor that his right knee disability aggravates his left knee. As a layperson, the Veteran is competent to report a contemporary medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). His competent report is presumed to be credible for the purpose of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The new evidence is material, because it tends to make more likely the unestablished element of causation or aggravation of the current left knee disorder by the service-connected right knee disorder. Because new and material evidence has been received, the claim of entitlement to service connection for a left knee disorder will be reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Service Connection Service connection will be granted for a current disability that results from an injury or disease incurred in, or aggravated by, active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, service connection requires a present disability, an in-service incurrence or aggravation of a disease or injury, and a nexus between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Generally, for a veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain listed chronic diseases, including organic diseases of the nervous system, if the disability manifests to a compensable degree within the one year of discharge from service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the listed chronic conditions, a showing of a continuity of symptomatology is an alternative method of establishing service connection. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Service connection may be granted on a secondary basis for disability which is proximately due to, or the result of, a service-connected disease or injury. Any increase in severity of a non-service-connected disease or injury that is proximately due to, or the result of, a service-connected disease or injury, and not due to the natural progress of the non-service-connected disease will be service-connected. 38 C.F.R. § 3.310; see also, Wallin v. West, 11 Vet. App. 509, 512 (1998). The claimant will be given the benefit of the doubt as to any issue material to the determination of a matter when there is an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for right shoulder. In January 1996, the Veteran filed a service-connection claim for injury to the right shoulder. A rating decision of September 1996 denied the claim of the basis that it was not well grounded. The Veteran did not appeal. In August 2012, the Veteran filed a service-connection claim for right shoulder condition. A rating decision of November 2012 denied service connection on the grounds that no new and material evidence had been received. The Veteran filed a NOD in January 2013 and VA Form 9 in October 2015. In February 2021, the Veteran stated on the record that he wished to withdraw his appeal as to entitlement to an increased rating for his service-connected right knee disability. Because he has withdrawn the appeal, there remains no allegation of an error of fact or law for appellate consideration. The Board does not have jurisdiction to review the appeal, and it will be dismissed. 38 U.S.C. § 7105; 38 C.F.R. §§ 20.202, 20.204. 5. Entitlement to service connection for PTSD. In August 2012, the Veteran filed a service-connection claim for PTSD. The scope of the claim includes any disability that may reasonably be encompassed by the Veteran’s description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board determines that a preponderance of the evidence is against finding entitlement to service connection for PTSD. As explained in a section below, service connection for major depressive disorder will be granted. Establishing service connection for PTSD generally requires: (1) medical evidence diagnosing PTSD in conformance with established criteria; (2) a link, established by medical evidence, between a veteran’s present symptoms and an in-service stressor; and (3) credible supporting evidence that the claimed in-service stressor actually occurred. 38 C.F.R. §§ 3.304(f), 4.125; see also Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). An August 2015 VA examination for PTSD diagnosed PTSD, which was attributed to the two stressors of witnessing the accidental death of a friend and viewing combat pictures and hearing combat stories while in service. The Veteran has attributed his PTSD to three events: 1) witnessing his friend, M. M., die in his arms after being struck by a vehicle when crossing the street, with the date of the accident variously given as 1995 or 1996; 2) witnessing fellow service-member “Kelly” being fatally run over by a truck during field maneuvers, with no date being given variously as the spring and late part of 1994; and 3) witnessing his drill instructor committing suicide during service, with no date being given. The AOJ notified the Veteran in February 2010, September 2012, and June 2015 as to evidence that could be used to corroborate his alleged PTSD stressors and as to the need for more specific information in order for VA to attempt to verify that the alleged stressors occurred. The Veteran was specifically informed in September 2012 that VA may accept satisfactory lay or other evidence of in-service occurrence, if the evidence is consistent with the conditions and circumstances of his service. A VA memorandum of July 2015 made a formal finding of a lack of information required to corroborate the stressors associated with the PTSD claim. It was noted that the Veteran had not responded to VA’s request for: a two-month time frame for when M.M. was struck by a car and died, for Kelly’s last name, and for a two- month time frame for Kelly’s fatal accident. It was determined that all efforts to obtain the information had been exhausted and that any further attempt would be futile. In this case, following multiple requests that the Veteran provide pertinent facts, it is not possible to corroborate the alleged in-service stressors, and the claim will be decided based on the evidence of record. For each alleged stressor, there is a lack of sufficient information as to the identity or time that might lead to corroboration that an in-service stressor occurred. The Veteran has been diagnosed with PTSD. Service connection for the disorder must be denied, because there is no record evidence that corroborates an in-service stressor. The Veteran is unable or unwilling to provide Kelly’s last name (the accident fatality) or the name of his drill instructor (the suicide victim), or to narrow down any of the relevant events to a two-month timeframe. No exception as to the requirement of credible supporting evidence of an in-service stressor applies, because the Veteran is not a combat veteran and was not a prisoner of war, and the claimed stressors are unrelated to a personal assault or a fear of hostile military or terrorist activity. 38 C.F.R. § 3.304(f). A preponderance of the evidence is against finding credible supporting evidence that the claimed in-service stressors occurred, and the PTSD claim fails on his basis. 38 C.F.R. § 3.304(f); see also Nat'l Org. of Veterans' Advocates v. Sec'y of Veterans Affairs, 330 F.3d 1345, 1351- 52 (Fed. Cir. 2003). 6. Entitlement to service connection for an acquired psychiatric disorder other than PTSD. In August 2012, the Veteran filed a service-connection claim for PTSD, which was denied by a November 2012 rating decision. He filed a NOD in January 2013 and VA Form 9 in October 2015. As explained above, today’s order reopens and denies the service connection claim for PTSD, which was previously denied in March 2010. With the reopening of his PTSD claim, the Veteran is entitled to an adjudication not only of entitlement to service connection for PTSD, but to any acquired psychiatric disorder that may reasonably be encompassed by his description of the claim, reported symptoms, and other information of record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board determines that the criteria for entitlement to service connection for major depressive disorder are met. The Veteran has been diagnosed with current psychiatric disorders other than PTSD. A VA treatment record of November 2012 diagnosed bipolar I disorder NOS, PTSD, and alcohol dependence. Alcohol-induced mood disorder was ruled out (“r/o”) by a VA treatment record of January 2010. A VA treatment record of November 2012 diagnosed PTSD, major depressive disorder with psychotic features, and alcohol dependence in a controlled environment. A VA treatment record of July 2013 diagnosed PTSD, depression NOS, and ETOH dependence. The August 2015 VA examination report for PTSD diagnosed the Veteran as having PTSD and major depressive disorder. A VA treatment record of December 2018 made an assessment of severe alcohol use disorder in early remission and unspecified anxiety disorder. In October 1994, during service, the Veteran was diagnosed with alcohol dependence, adjustment disorder with mixed disturbance of emotions and conduct, and polysubstance abuse in remission. A service treatment record of September 1995 diagnosed maladjustment disorder, alcohol dependence, anxiety, and personality disorder. The DD Form 214 notes that the basis for his honorable discharge was personality disorder and alcohol rehabilitation failure. Nonetheless, the separation examination report of October 1995 found the Veteran to be psychologically normal. For the Report of Medical History at separation, the Veteran answered “yes” as to past or current frequent trouble sleeping, depression or excessive worry, and loss of memory or amnesia. The Board finds the Veteran to be competent and credible in his report of disturbing and upsetting events during service (specifically, the witnessed truck-accident fatality of a fellow service member and the witnessed suicide of his drill instructor, as described in the section above relating to PTSD) and of recurrent psychiatric symptoms that began in service and have continued to the present. Special regulatory requirements relating to credible supporting evidence that a claimed in-service stressor occurred apply to PTSD claims and not to other psychiatric disabilities generally. 38 C.F.R. § 3.304(f). In the opinion of the August 2015 VA examiner for PTSD, it is at least as likely as not that the Veteran’s diagnosed mental disorders were incurred in, or caused by, his military service, are a continuation of the in-service diagnosis of adjustment disorder, and are not caused by alcohol abuse or dependence. The opinion was based on the examiner’s examination of the Veteran and review of the relevant medical and service history as reflected in the claims file. The examiner diagnosed PTSD and major depressive disorder. Because the Veteran reported having sudden outbursts of anger after a period of calm, the examiner found that he did not meet the diagnostic criteria for bipolar disorder under the DSM-5. Evidence that tends to weigh against the claim is an August 2015 addendum VA medical opinion (based on a review of the record and not authored by the August 2015 VA examiner) that there is a “pattern of significant premilitary psychological problems” and that the psychiatric issues noted during military service were part of a longstanding pattern that was being exacerbated by recent stressors. The Veteran was noted to be psychologically normal on the entrance examination report of July 1993. Therefore, he is presumed to have been sound upon entry, and the presumption is not rebutted by clear and unmistakable evidence that he had a preexisting psychiatric disorder that was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The Board finds the positive evidence of record, including the opinion of the August 2015 VA examiner that links current psychiatric symptoms to the in- service diagnosis of adjustment disorder, to be more probative than the negative evidence of record. With all three elements of service connection having been met, the claim will be granted. 7. Entitlement to service connection for tinnitus. In August 2012, the Veteran filed a service-connection claim for tinnitus, which was denied by a rating decision of November 2012. He appealed by filing a NOD in January 2013 and VA Form 9 in October 2015. A January 2021 rating decision granted service connection for a hearing loss disability of the left ear. A noncompensable rating, effective November 25, 2019, was established. Service connection for hearing loss of the right ear was denied. The Veteran testified before the Board that his ringing in the ears began during service but that he did not seek treatment or report the symptom at the time. He attributes his tinnitus to noise exposure from working around the loud noise of tanks during service. He stated that, following service, he has worked as a truck driver and has not been in an environment of a high noise level. The Veteran’s DD Form 214 and personnel records indicate that his military occupational specialty was maintenance battle tank repairer/technician. Tinnitus is not noted in the service treatment records or on the October 1995 examination report of service separation. For the Report of Medical History at separation, the Veteran checked “Don’t Know” when asked as to any past or current hearing loss. The Veteran underwent a VA audiological examination in December 2020. The examiner indicated that “the ringing began in service,” that the Veteran’s memory problems made pinpointing a date difficult, and that hearing loss had been noted on the report of the Veteran’s separation examination in October 1995. The examiner did not provide an explicit etiology opinion, because VA had not requested one. In this case, there is sufficient evidence of in-service noise exposure and of ringing in the ears experienced first during service and recurring to the present. Tinnitus is capable of lay observation. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). The Veteran’s exposure to acoustic trauma in service is consistent with the circumstances of his occupational specialty of tank repair. 38 U.S.C. § 1154(a). He has given a competent and credible account of his exposure to loud noise during service and his experienced symptom of tinnitus during and following service. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board may not find a claimant’s lay statements regarding experienced symptoms to be not credible merely due to a lack of confirmatory medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Evidence that tends to weigh against the claim is the negative nexus opinion of a September 2012 VA examination report. The stated rationale was that the Veteran reported to the examiner that he did not notice tinnitus while serving in the military and that he could not recall when his tinnitus had its onset. The Veteran’s competent and credible reporting as to an in-service onset and recurrent symptoms to the present is not outweighed by the negative evidence of record. Any reasonable doubt as to whether tinnitus manifested during service is resolved in the Veteran’s favor. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As an organic disease of the nervous system, tinnitus is subject to the presumption of service connection established for chronic diseases that manifest during service or to a compensable degree during service within one year following service. 38 C.F.R. § 3.309(a). The Veteran’s current tinnitus, not being clearly attributable to an intercurrent cause, is presumed to be related to the tinnitus that manifested during service. 38 C.F.R. § 3.303 (b); see also Brannon v. Derwinski, 1 Vet. App. 314, 315 (1991). REASONS FOR REMAND 8. Entitlement to service connection for a left knee disorder is remanded. The Veteran is currently service-connected for status post total right knee replacement. A November 2018 treatment record of Dr. S. M. diagnoses severe degenerative joint disease of both knees. The Veteran contended in his hearing testimony before the Board, and elsewhere in the record, that his service-connected right knee disability causes or aggravates his left knee disorder. A September 2012 treatment record of Dr. M. H. notes the Veteran’s report that he puts too much weight on his left knee, that the left knee has become damaged, and that the pain is severe due to “babying” of the right knee. The doctor did not offer an opinion as to whether the right knee disability causes or aggravates the left knee disorder. While the Veteran is competent to report his experienced symptoms, he is not competent to identify the right knee as the cause or aggravating circumstance of his left knee disorder. The Veteran underwent a VA examination for the knees in October 2012. A negative opinion was offered as to the likelihood of secondary service connection. The rationale was that there was no medical evidence that chondromalacia patella in one knee will cause arthritis in the other knee, and that the Veteran has arthritis in his bilateral feet and a history of gout. A further VA opinion based on records review was obtained in July 2015. In the clinician’s opinion, there was no evidence that the left knee was aggravated beyond normal disease progression in terms of an increase in the frequency or severity of symptoms due to the right knee. No rationale was offered. A VA examination and medical opinion must be adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, an adequate nexus opinion must take into account the Veteran’s competent report as to the onset and history of the claimed disorder. See Miller v. Wilkie, 32 Vet. App. 249, 257 (2020). The VA opinions of record give no indication that consideration was given to the Veteran’s competent report to Dr. M. H. that he “babies” his right knee by putting extra weight on his left knee. Furthermore, no rationale was offered for the negative opinion of the July 2015 VA clinician. Therefore, the Board will remand for an addendum VA opinion. 38 C.F.R. § 19.9(a). The matter is REMANDED for the following action: 1. Undertake appropriate development to associate with the record any outstanding and identified private medical records that are pertinent to the remanded issue and any outstanding VA treatment records. All efforts to obtain such records should be documented in the electronic claims folder. 2. Obtain an addendum opinion from an appropriate clinician regarding the nature and etiology of the Veteran’s left knee disorder. A further in-person examination may be scheduled if needed to adequately provide the requested opinion. The clinician must opine as to whether the Veteran’s current left knee disorder at least as likely as not: a. Is related to an in-service injury, event, or disease; b. Began during active service, manifested within one year after discharge from service, or was noted during service with continuity of the same symptomatology since service; or c. Is proximately due to, or aggravated beyond its natural progression by, a service- connected disability, to include the service-connected disability of the right knee, or by any other disorder. Notify the clinician that the Veteran, as a layperson, is competent to report his experienced left knee symptoms. If there is a medical basis to support his reported history of symptoms, the clinician must indicate this in the examination report and provide a rationale for that determination. Notify the clinician that, if an opinion cannot be provided without resorting to mere speculation, he or she shall explain why an opinion cannot be given. In so doing, the clinician shall explain whether the inability to provide the opinion is the result of a need for additional information, or that the clinician has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). Notify the clinician that the term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. The clinician must offer a rationale for all opinions in the report. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Steven D. Najarian, 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.