Citation Nr: 21023012 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 17-56 130A DATE: April 19, 2021 ORDER Entitlement to service connection for a dental disability is denied. REMANDED Entitlement to service connection for a dental disability for the purpose of obtaining VA outpatient treatment is remanded. Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left hip disorder is remanded. Entitlement to service connection for a right hip disorder is remanded. Entitlement to service connection for a bilateral calf disorder is remanded. Entitlement to service connection for a bilateral foot disorder is remanded. Entitlement to service connection for a right hand/finger disorder is remanded. Entitlement to service connection for a left hand/finger disorder is remanded. Entitlement to service connection for a neck disorder is remanded. Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for tinnitus is remanded. FINDING OF FACT The Veteran does not have a dental disorder as a result of loss of bone due to disease or other trauma during his active military service. CONCLUSION OF LAW The criteria for entitlement to service connection for dental disorder have not been met. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 4.150. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from December 1957 to December 1960 and from January 1961 to December 1963. The Veteran has filed a claim for issues relating to the extraction of his teeth. In Mays v. Brown, 5 Vet. App. 302 (1993), the United States Court of Appeals for Veterans Claims (Court) held that a claim for service connection for a dental condition is also a claim for outpatient dental treatment. As such, Board will consider Veteran’s claim for a dental disability to be both for the purpose of compensation and for the purpose of outpatient treatment. Entitlement to service connection for a dental disorder. The Veteran seeks service connection for a dental disorder due to the extraction of his teeth during military service. He reports that during his first period of service, he sought dental treatment to receive three dental bridges, but he was informed that the Army would not provide such service because it was too costly. Instead, the remainder of his teeth were extracted, and he was provided with a dental replacement that did not fit properly. The Veteran believes that he should be awarded VA compensation for the loss of his teeth. See Correspondence (September 2013), and Correspondence (April 2014). Entitlement to VA compensation may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110; 1131; 38 C.F.R. § 3.303. To establish a right to compensation for a present disability, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service”-the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under current VA regulations, service-connected compensation is only available for certain types of dental and oral conditions. See 38 C.F.R. § 4.150. Compensation is available under Diagnostic Code 9913 for loss of teeth if such is “due to loss of substance of body of maxilla or mandible.” Diagnostic Code 9913 also states that it applies only to bone loss through trauma or disease such as osteomyelitis, and not the loss of alveolar process as a result of periodontal disease, since such loss is not considered disabling. See Note, 38 C.F.R. § 4.150, Diagnostic Code 9913. Replaceable missing teeth are not compensable disabilities. See 38 C.F.R. § 3.381. The Veteran’s in-service dental records reflect that upon his enlistment into service, he was missing teeth numbered 10, 13, and 30, and during service he received dental treatment, to include care for periodontal abscess, dental caries, and the extraction of the remainder of his teeth. In April 1960, the Veteran was provided with full upper and lower dental dentures. See STR-Dental (March 2014). The Veteran has not claimed that any dental trauma occurred in service, beyond the dental treatment that he was provided. After review, the Board finds there is no evidence in the Veteran’s service treatment records that he experienced loss of teeth due to loss of substance of the maxilla or mandible due to any in-service dental trauma or disease. The Veteran’s teeth were extracted during service, and there is no indication in the record that that this extraction was due to loss of substance of the maxilla or mandible for any event that occurred in service. Thus, service connection may not be established for compensation purposes for missing teeth purposes under 38 C.F.R. § 4.150. The Board acknowledges that the Veteran has outstanding records from Social Security Administration (SSA), which are being addressed in the remand portion below. However, there is no indication that those SSA records are relevant to the Veteran’s claim for service connection for dental disorder in order to obtain VA compensation. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has specifically held that VA’s duty to assist is limited to obtaining relevant SSA records, and relevant records have been defined as “those records that relate to the injury for which the claimant is seeking benefits and have a reasonable possibility of helping to substantiate” the claim. Golz v. Shinseki, 590 F.3d 1317, 1321 (2010). Here, the Veteran has not asserted, and the record does not show, he sustained a dental trauma or disease during his military service which is necessary for award of service connection for loss of teeth for compensation purpose, and any records from SSA created decades after the Veteran’s period of service would not be relevant to this issue. Accordingly, the Board finds that failure to obtain those SSA records prior to adjudicating this claim is not prejudicial. REASONS FOR REMAND In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. 1. Entitlement to service connection for a dental disability for the purpose of obtaining VA outpatient treatment is remanded. As noted in the Introduction, the Veteran’s claim for service connection for a dental condition is also a claim for outpatient dental treatment, and a remand is needed to ensure the claim is processed properly. VA regulations governing concerning a claim for service connection for dental disability for the purpose of obtaining VA outpatient dental treatment provide that the Veterans Benefits Administration (VBA) will adjudicate a claim for service connection of a dental condition for treatment purposes after the Veterans Health Administration (VHA) determines that a veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161 and requests that VBA make a determination on relevant questions. See 38 C.F.R. § 3.381 (a). While the Regional Office (RO) adjudicated and denied the claim for entitlement to service connection for a dental disability for compensation purposes, the record shows that the RO did not refer the claim to VHA for consideration of service connection for a dental disability for purposes of VA outpatient treatment purposes which is required under 38 C.F.R. §§ 17.161 and 38 C.F.R. § 19.9 (b). As a result, the Board finds that a remand is appropriate in order to instruct the RO to refer the claim to the VHA, which the regulation provides must make the initial determination on the claim, will better ensure that the claim is addressed promptly and efficiently and is therefore consistent with the uniquely pro-claimant principles underlying the veterans’ benefits system. Nat’l Org. of Veterans Advocates, Inc. v. Sec’y of Veterans Affairs, 710 F.3d 1328, 1330 (Fed. Cir. 2013). 2. Entitlement to service connection for a lumbar spine disorder is remanded. 3. Entitlement to service connection for a left knee disorder is remanded. 4. Entitlement to service connection for a right knee disorder is remanded. 5. Entitlement to service connection for a left hip disorder is remanded. 6. Entitlement to service connection for a right hip disorder is remanded. 7. Entitlement to service connection for a bilateral calf disorder is remanded. Remanded Issues 2-7: The Veteran seeks entitlement to service connection for lumbar spine, bilateral knee, bilateral hip, and bilateral calf disorders. He asserts that his current disorders are a result of injury he sustained when he fell off a hill and landed on his knees while he was stationed in Korea during service. He further reports the onset of his back, knee, and hip problems following the injuries sustained from that fall. He believes that his current problems can be traced back to the injuries sustained in service which resulted in an altered gait and have caused by a “domino” effect throughout his musculoskeletal and neural systems. See Correspondence (September 2013), Correspondence (April 2014), and Congressional (August 2018). To ensure that VA has met its duty to assist, a remand is necessary for the following reasons. Initially, the Board notes that the record indicates there may be outstanding and relevant Social Security Administration (SSA) records. The Veteran’s treating physician noted that he has been in receipt of disability benefits related to his musculoskeletal complaints since 2011. See Medical Treatment Record - Non-Government Facility (September 2013). No clear determination as to the availability of any records which may have been in the possession of the SSA has been made. The Court has indicated that medical records upon which an award of Social Security disability benefits has been predicated are relevant to VA claims for service connection. Murincsak v. Derwinski, 2 Vet. App. 363 (1992). A remand is required to allow VA to request these records. Next, addendum VA medical opinions are needed regarding the etiology of the Veteran’s lumbar spine, bilateral knee, and bilateral hip disorders. The medical evidence demonstrates that the Veteran has degenerative changes in his lumbar spine, bilateral knees, and bilateral hips. See CAPRI (December 2016). VA obtained July 2014 VA medical opinions that addressed whether the Veteran’s current lumbar spine and bilateral knee disorders were related to his in-service injury, to include in-service complaints of back and knee pain. See C&P Exam, Medical Opinion Report (July 2014). Since then, the Veteran has submitted additional private medical statements from R.E.G., D.C. dated in May 2014 and August 2016, which discuss how the Veteran’s reported fall-related injuries resulted in altered biomechanics and caused his current degenerative changes. See Medical Treatment Record - Non-Government Facility (March 2016) and (September 2016). Even though the additional private medical statements contain favorable medical nexus opinions between the Veteran’s current back and knee disorders and his reported in-service injury, the opinion is not based on a full review and discussion of the Veteran’s medical and personal history when in comparison to the July 2014 VA medical opinions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating that “most of the probative value of a medical opinion comes from its reasoning”); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (stating that to be adequate, a medical opinion “must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions”). Regardless of the deficiencies in the private medical statements, they trigger the need for addendum VA medical opinions on the etiology of the Veteran’s current lumbar spine, bilateral knee, and bilateral hip disorders in consideration the findings raised in the private medical statements. See Colvin v. Derwinski, 1 Vet. App. 171 (1991); see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence... is essential for a proper appellate decision”). Finally, no VA medical opinion has been obtained that addresses whether the Veteran’s current bilateral knee, hip, and calf symptoms constitute a permanent aggravation of the pre-existing genu valgus in his lower extremities noted on his December 1957 enlistment examination report. VA’s duty to obtain a VA with a medical opinion has been triggered. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006) (a VA examination and/or opinion is warranted when there is an indication in the record that a current disability is related to military service; the threshold for an indication is low). The Veteran’s December 1957 enlistment examination report shows that his lower extremities were evaluation as abnormal, and a notation of genu valgus, asymptomatic, was provided. Subsequent service treatment records show complaints of hip problem in May 1958, findings of patella tenderness in August 1959, complaints of painful knees in October 1960, complaints of burning knee pain and impression of post-traumatic arthritis, rule out neuritis in November 1960 (although x-ray films were negative in October 1960), and a history of injured left knee in October 1960. See STR – Medical (March 2014). A remand is needed to obtain a VA medical opinion to clarify whether the Veteran’s current knee, hip, and calf symptoms constitute either a new disability or a permanent aggravation of the Veteran’s pre-existing genu valgus beyond the natural progression of the disease. 8. Entitlement to service connection for a bilateral foot disorder is remanded. The Veteran seeks entitlement to service connection for a bilateral foot disorder. He asserts that his current foot problems are result of injury incurred during his period of service. The Veteran believes that his current bilateral foot problems can be traced back to the injuries sustained from his fall which resulted in altered gait and have now caused by a “domino” effect throughout his musculoskeletal and neural systems. See Correspondence (September 2013), Correspondence (April 2014), and Congressional (August 2018). Pertinently, the Veteran’s service treatment records contain complaints of foot pain and show he was prescribed shoe inserts to treat fallen arches in August 1962. He was also treated for a bunion on his right fifth toe in October 1962. See STR- Medical (service treatment records) (March 2014). Although the available post-service medical records do not show treatment for bilateral foot complaints, the Veteran has provided a history of such problems when he initiated his claims for service connection. See VA 21-526 Veterans Application for Compensation or Pension (September 2013). VA has not yet obtained an examination or medical opinion in this matter, and VA’s duty to obtain a VA examination with a medical opinion has been triggered. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). See also McLendon, supra. Indeed, a VA examination is needed to determine whether the Veteran has any current foot disorder that had its onset during his military service, or is otherwise related to his period of service, to include in-service treatment for bilateral foot pain. Also, a remand is required to allow VA to request the Veteran’s SSA records. 9. Entitlement to service connection for right hand/finger disorder is remanded. 10. Entitlement to service connection for left hand/finger disorder is remanded. Remanded Issues 9-10: The Veteran seeks service connection for bilateral hand/finger disorder. He contends that his current bilateral hand/finger problems are a result of injury sustained during service. The Veteran believes that his current bilateral hand/finger problems can be traced back to the injuries sustained from his fall which resulted in altered gait and have now caused by a “domino” effect throughout his musculoskeletal and neural systems. See Correspondence (September 2013). The Veteran’s December 1957 examination prior to enlistment shows that he had an amputation at the medial joint of the right little finger and similar notations are documented on his October 1960 and October 1963 examinations prior to separation. In addition, the Veteran’s service treatment records show he was treated for laceration of his right index finger in August 1959 and treated for sprain of radial collateral ligament of PID joint right ring finger in November 1960. See STR-Medical (March 2014). The Veteran has described functional impairment in his fingers when they freeze up and need to be message to unlock them. See Correspondence (September 2013). VA treatment records also show findings of fixed deformity right fourth finger. See CAPRI (December 2016). VA has not yet obtained an examination or medical opinion in this matter, and VA’s duty to obtain a VA examination with a medical opinion has been triggered. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). See also McLendon, supra. Indeed, a VA examination and medical opinion is needed to determine whether the Veteran has a current right hand/finger disorders that is a result of his period of service, to include aggravation of his pre-existing right little finger amputation at medial joint. Also, a remand is required to allow VA to request the Veteran’s SSA records. 11. Entitlement to service connection for a neck disorder is remanded. The Veteran seeks entitlement to service connection for a neck disorder. He asserts that his current neck problems are result of injury incurred during his period of service. The Veteran believes that his current neck problems can be traced back to the injuries sustained from his fall, which resulted in altered gait and have now caused by a “domino” effect throughout his musculoskeletal and neural systems. See Correspondence (September 2013). The Veteran’s service treatment records show that he complained of neck pain in March 1962. See STR-Medical (March 2014). The Veteran has reported treatment for neck problems, and he contends that his current neck problems are a result of injury he sustained during service. He has also reported that his treating chiropractor has informed that his neck problems can be traced back to injuries sustained while in service, albeit such a medical statement is not contained in the available medical records. See Correspondence (September 2013); VA 21-4142 Authorization for Release of Information (June 2014). VA has not yet obtained an examination or medical opinion in this matter, and VA’s duty to obtain a VA examination with a medical opinion has been triggered. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). See also McLendon, supra. Indeed, a VA examination and medical opinion is needed to determine whether the Veteran has a current neck disorder that had an onset during his period of service, or it otherwise related to his period of service, to include in-service complaints of neck pain. Also, a remand is required to allow VA to request the Veteran’s SSA records. 12. Entitlement to service connection for a right shoulder disorder is remanded. 13. Entitlement to service connection for a left shoulder disorder is remanded. Remanded Issues 12-13: The Veteran seeks service connection for his bilateral shoulder disorders. He reports that he that injured his shoulder while playing football during service, and although he sought treatment at time, he was only advised that he needed hot shower. He was not provided with x-ray or further medical attention. The day following his shoulder injury, the Veteran reports he was required to perform heavy lifting with one arm. The Veteran reports that years later, he was informed that he a fractured left collar-bone. He believes the fractured left collar-bone was a result of the football injury. See Correspondence (September 2013). In addition, the Veteran believes that his current shoulder problems can be traced back to the injuries sustained from his fall, which resulted in altered gait and have now caused by a “domino” effect throughout his musculoskeletal and neural systems. See Correspondence (September 2013), Correspondence (April 2014), and Congressional (August 2018). The service treatment records do show that the Veteran sought treatment for left shoulder pain in August 1961. See STR-Medical (March 2014). In addition, a May 2014 private medical statement from R.C.S, DC contains a medical opinion that the Veteran’s current shoulder problems are more likely than not all result of injuries sustained from fall while stationed in Korea. See Medical Treatment Record - Non-Government Facility (March 2016). Unfortunately, no further explanation was provided, nor was a full review of the evidence indicated, and this medical opinion contains very limited, if any, probative value. See Nieves-Rodriguez, supra; see also Stefl, supra. Although the Board finds that the opinion is inadequate to grant service connection, it is sufficient to trigger VA’s duty to assist and the need to obtain a VA medical opinion in this matter. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). See also McLendon, supra. Indeed, a VA examination and medical opinion is needed to determine whether the Veteran has a current bilateral shoulder disorder that had an onset during his period of service, or it otherwise related to his period of service, to include in-service complaints of left shoulder pain. Also, a remand is required to allow VA to request the Veteran’s SSA records. 14. Entitlement to service connection for bilateral hearing loss 15. Entitlement to service connection for tinnitus Remanded Issues 14-15: The Veteran seeks entitlement to service connection for bilateral hearing loss and tinnitus as a result of exposure to loud noises during his period of service. He reports that while performing duties in the communication center, he exposed to loud noises from machines without hearing protection. He further reports that his ears started ringing in service and have continued to ring since then, and he did not have any hearing problems prior to service. See Correspondence (September 2013). A remand is needed to allow VA to request the Veteran’s SSA records. The possibility that SSA records could contain relevant evidence in regard to these claims cannot be foreclosed absent a review of those records. Quartuccio v. Principi, 16 Vet. App. 183, 188 (2002). The matters are REMANDED for the following action: 1. Refer the claim for dental treatment to the appropriate VA Medical Center (VAMC) to determine if the Veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161. If the VAMC determines that the Veteran meets the basic eligibility requirements of 38 C.F.R. § 17.161 and requests VBA make a determination, then adjudicate the claim. 2. Obtain the Veteran’s federal records from SSA. Document all requests for information as well as all responses in the claims file. 3. Obtain the Veteran’s VA treatment records for the period from October 2016 to the Present. 4. Obtain an addendum VA medical opinion that for the Veteran’s lumbar spine disorder. The examiner must review the claims file. Based on review of the record, medical and lay evidence, detail the symptoms in service and thereafter, including the nature, onset, progression and severity of the Veteran’s reported symptoms. Then address: (a.) Whether the Veteran’s degenerative arthritis of the lumbar spine is at least as likely as not related to service, including result of any altered gait due injuries to the hip, knees, and feet, and/or in-service complaints of back problems in August 1959 and March 1960. (b.) Whether it is at least as likely as not that the degenerative arthritis of the lumbar spine (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 5. Schedule the Veteran for a VA examination for bilateral knee, bilateral hips, and bilateral calf disorder. The examiner must review the claims file. Detail the symptoms in service and thereafter, including the nature, onset, progression and severity of the Veteran’s reported symptoms. Then address the following: (a.) Identify whether the Veteran has any current disability involving the Veteran’s bilateral calf. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. (b.) Whether the Veteran’s pre-existing genu valgus in the lower extremities was at least as likely as not aggravated (non-temporary increase in severity) by service and, if so, whether any increase in severity was clearly and unmistakably (undebatable) due to its natural progress. (c.) Whether any current hip, knee, and/or calf disability is at least as likely as not related to an in-service injury, event, or disease, to include including result of any altered gait due injuries to the hips, knees, and feet, and/or in-service complaints of knee and hip problems. (d.) The examiner should consider the in-service complaints of hip problem in May 1958, findings of patella tenderness in August 1959, complaints of painful knees in October 1960, complaints of burning knee pain and impression of post-traumatic arthritis, rule out neuritis in November 1960 (although x-ray films were negative in October 1960). (e.) Whether it is at least as likely as not that the degenerative arthritis in the knees and hips (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 6. Schedule the Veteran for a VA examination for his claimed bilateral feet disorder. The examiner must review the claims file. Detail the symptoms in service and thereafter, including the nature, onset, progression and severity of the Veteran’s reported symptoms. Then address the following: (a.) Determine whether the Veteran has any current diagnosed foot disorders. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. (b.) For each foot disability, is it at least as likely as not related to service, to include as result of in-service complaints of right and left foot problems? (c.) The examiner should consider the Veteran’s in-service treatment for fall arches in August 1962, and treatment for right fifth toe bunion in October 1962. 7. Schedule the Veteran for a VA examination for his claimed neck disorder. The examiner must review the claims file. Detail the symptoms in service and thereafter, including the nature, onset, progression and severity of the Veteran’s reported symptoms. Then address the following: (a.) Identify whether the Veteran has a current diagnosed neck disorder. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. (b.) Whether any current diagnosed neck disorder is at least as likely as not related to service, including a result of including result of any altered gait due injuries to the hips, knees, and feet, and/or in-service complaints of neck pain in March 1962. (c.) For any diagnosed arthritis of the cervical spine, is it at least as likely as not that the degenerative arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 8. Schedule the Veteran for a VA examination for his claimed right hand/finger disorder. The examiner must review the claims file. Detail the symptoms in service and thereafter, including the nature, onset, progression and severity of the Veteran’s reported symptoms. Then address: (a.) Identify whether the Veteran has any current diagnosed disorders involving the right hand and fingers. (b.) Whether the Veteran’s pre-existing right little finger amputation at medial joint was at least as likely as not aggravated (non-temporary increase in severity) by service and, if so, whether any increase in severity was clearly and unmistakably (undebatable) due to its natural progress. (c.) Whether any current right hand and/or finger disorder is at least as likely as not related to an in-service injury, event, or disease, to include laceration injury to right index finger in August 1959 and sprained right ring finger in November 1960. (d.) For any diagnosed arthritis involving the hand and/or finger, is it at least as likely as not that the degenerative arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 9. Schedule the Veteran for a VA examination for his claimed bilateral shoulder disorder. The examiner must review the claims file. Detail the symptoms in service and thereafter, including nature, onset, progression and severity of the Veteran’s reported symptoms. Then address the following: (a.) Identify whether the Veteran has any current diagnosed shoulder disorder. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. (b.) Whether any current diagnosed shoulder disorder is at least as likely as not related to service, to include as result of any altered gait due injuries to the hips, knees, and feet, and/or in-service complaints of shoulder pain in August 1961. (c.) For any diagnosed arthritis involving the shoulder, is it at least as likely as not that the degenerative arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 10. Ensure that the VA medical opinions obtained includes a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 11. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Murray 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.