Citation Nr: 21023634 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 16-05 846 DATE: April 21, 2021 ORDER Entitlement to service connection for vitamin D deficiency, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for hoarseness, to include as secondary to a service-connected disability, is denied. REMANDED Entitlement to service connection for pleuritic chest pain, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for heart condition, to include congestive heart failure, and to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for sleep apnea, to include as secondary to a service-connected disability, is remanded.   Entitlement to service connection for a digestive disorder, to include gastric ulcers, gastroenteritis, and gastroesophageal reflux disease (GERD) but excluding irritable bowel syndrome (IBS), and to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for left foot neuropathy, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for right foot neuropathy, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for left shoulder degenerative joint disease, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for neck condition, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for chronic fatigue syndrome, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for restless leg syndrome, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for gout, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for right kidney cyst, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for urinary incontinence, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for migraine headaches, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for otitis media, to include as secondary to a service-connected disability, is remanded.  FINDINGS OF FACT 1. Vitamin D deficiency is not a disability for VA compensation purposes. 2. The preponderance of the evidence weighs against a finding that the Veteran has had a chronic hoarseness disability at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. The criteria for service connection for vitamin D deficiency are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for hoarseness are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from June 1980 to March 1986. These matters are before the Board of Veterans’ Appeals (Board) on appeal from April 2014, January 2015, March 2015, and December 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the Board at a hearing held by the undersigned in March 2019. A transcript of the hearing is of record. Subsequently, the Board remanded the claims currently before the Board in an October 2019 decision.   In the October 2019 decision, the Board also remanded the Veteran’s claims of entitlement to service connection for insomnia and for an eye condition, to include blepharitis. In an August 2020 rating decision, the Agency of Original Jurisdiction (AOJ) awarded service connection for adjustment disorder with depressed mood and insomnia and for dry eye syndrome with blepharitis. As the August 2020 awards of service connection for adjustment disorder with depressed mood and insomnia and for dry eye syndrome with blepharitis encompasses the Veteran’s claims, the claims have been fully resolved and are no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Lastly, regarding the claim of service connection for a heart condition, the Veteran filed a claim for service connection for congestive heart failure. As the record indicates that the Veteran may have been diagnosed with other heart conditions, the Board has recharacterized the issue to be for service connection for any heart condition to ensure that all potential diagnoses related to the heart are considered. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Service Connection Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Under 38 C.F.R. § 3.310, secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).  1. Entitlement to service connection for vitamin D deficiency is denied. The Veteran contends his vitamin D deficiency is secondary to his service-connected irritable bowel syndrome (IBS) and his nonservice-connected digestive disorder. See Board Hearing Transcript, dated March 2019; VA Form 9, Appeal to Board of Veterans’ Appeals, dated February 2016. The Veteran’s diagnosed vitamin D deficiency itself is not a service-connectable disability. The term “disability,” as used for VA purposes, refers to a condition resulting in an impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The record does not suggest that the Veteran’s Vitamin D deficiency reaches the level of a functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356, 1367-69 (Fed. Cir. 2018) (holding that “pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability” if it “reaches the level of a functional impairment of earning capacity”). Rather, the Veteran’s vitamin D deficiency is a laboratory-confirmed clinical finding of abnormal blood chemistry characterized by a lack of sufficient vitamin D. See Dorland’s Illustrated Medical Dictionary 2068 (32nd ed. 2012). Although vitamin D deficiency may be considered a risk factor in the development of certain diseases it is not a disease, injury, or disability, in and of itself, for which VA compensation benefits are payable. Cf. 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (stating that diagnoses of hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities; therefor, they are not appropriate entities for the rating schedule). Because a vitamin D deficiency is not a current disability for which service connection may be granted, the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the Veteran’s claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.   2. Entitlement to service connection for hoarseness is denied. The Veteran contends his hoarseness is secondary to his service-connected COPD with frequent pneumonia or chronic sinusitis with allergic rhinitis and his nonservice-connected digestive disorder. See Board Hearing Transcript, dated March 2019; VA Form 9, Appeal to Board of Veterans’ Appeals, dated February 2016. The questions for the Board are whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease; or whether the Veteran has a current disability that is proximately due to or the result of or is aggravated beyond its natural progress by a service-connected disability. The Board concludes that the Veteran does not have a current diagnosis of hoarseness and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). A review of the record illustrates there is no diagnosis of hoarseness during the appeal period or recent to his filing of the claim, which was received by VA in March 2015. The Board acknowledges the Veteran’s March 2015 written statement in which he stated that he has a scratchy voice, that it hurts to talk, and that it sounds weak when he talks. Furthermore, the Board acknowledges the Veteran’s testimony at his March 2019 Board hearing that his hoarseness is a sore throat. In addition, the Veteran reported at his Board hearing that his service treatment records reflect that he had respiratory infections during service, which can cause sore throats. The Board also acknowledges that the Veteran reported at his Board hearing that he is treated a lot for hoarseness, which means he can barely speak. However, the Veteran was afforded a VA examination in February 2020 for an evaluation of any condition of the throat, larynx, and pharynx, and the VA examiner noted that no diagnosis of hoarseness was warranted. The examiner noted that the Veteran’s speech patterns, quality, volume, and clarity were all normal on examination. Furthermore, the VA examiner noted that the record reflects that the Veteran reported hoarseness in 2013, but the record does not include a diagnosis of hoarseness. The examination report reflects that the Veteran reported experiencing hoarseness manifested by a scratchy and dry throat with speech changes since the 1980s. However, while acknowledging the Veteran’s reports, the VA examiner indicated that this was a subjective complaint and not a diagnosed condition by a medical provider. The VA examiner concluded that the records and current examination did not provide objective evidence of a chronic condition of hoarseness. The existence of a current disability is the cornerstone of a claim for service connection and VA disability compensation. 38 U.S.C. § 1131; Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). Evidence must show that the Veteran currently has the disability for which benefits are being claimed. Here, the evidence does not reflect that the Veteran has had a chronic hoarseness disability at any point during the appeal period. Additionally, there is no indication the Veteran has had symptoms of the condition that have caused him any functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018); see also Wait v. Wilkie, 33 Vet. App. 8 (2020) (to establish the presence of a disability pursuant to Saunders, there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity). Here, the Board notes the Veteran’s reports that it sounds weak when he talks and that he can barely speak when he has hoarseness; however, the record, including the February 2020 VA examination report, reflects no competent and credible evidence that the Veteran’s alleged hoarseness rises to the level to affect earning capacity. Notably, the February 2020 VA examination report reflects that the Veteran’s alleged hoarseness causes no functional impact. Therefore, the Board cannot grant his claim under any theory of entitlement.   The Board does not question the Veteran’s sincerity in his belief that service connection is warranted for hoarseness. However, without evidence of a current hoarseness disability, a preponderance of the evidence is against the claim, and the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App., 49, 53-56 (1990). As such, service connection for hoarseness is denied. REASONS FOR REMAND 1. Entitlement to service connection for pleuritic chest pain is remanded. Initially, the Board notes that this claim must be remanded to afford the AOJ the opportunity to issue a supplemental statement of the case. Following the Board remand of this claim in October 2019 for further development, the Veteran submitted a written statement, dated February 12, 2020 and received by VA on February 12, 2020, that reflects that the Veteran wished to withdraw his claim for service connection for pleuritic chest pain. In a written statement, dated February 15, 2020 and received by VA on February 17, 2020, the Veteran reiterated that he wanted to withdraw his claim for service connection for pleuritic chest pain. In a written statement, dated February 18, 2020 and received by VA on February 19, 2020, the Veteran indicated that he did not want to withdraw any of the issues that the Board remanded. Furthermore, this statement reflects that the February 12, 2020 and February 15, 2020 statements should be disregarded, and that the claim for service connection for pleuritic chest pain should be continued. The Veteran submitted the February 18, 2020 statement again on March 11, 2020, where he reiterated his desire to continue his pleuritic chest pain claim. However, in the August 2020 supplemental statement of the case, the AOJ noted that the issue of entitlement to service connection for pleuritic chest pain was considered withdrawn. Therefore, the AOJ did not address the Veteran’s pleuritic chest pain claim on the merits. As the Veteran’s February 18, 2020 statement clearly illustrates that he wished to continue with this pleuritic chest pain claim, the Board must remand the claim for the issuance of a supplemental statement of the case. 38 C.F.R. § 19.31. In addition, the Veteran attended a VA examination in February 2020 for an evaluation of his pleuritic chest pain. The examination report reflects a diagnosis of chronic obstructive pulmonary disease with frequent pneumonia. Furthermore, the examination report reflects that: [f]or VA rating purposes, pain cannot be used as a diagnosis. Pain is a symptom of a broader disorder, and, given the [V]eteran’s significant pulmonary disorders, it would be impossible to state which disorder is responsible for the symptom of pleuritic chest pain without resorting to mere speculation. The examination report reflects that the Veteran reported intermittent pleuritic type chest pain. Therefore, as it is unclear from the record whether the Veteran has a pleuritic chest pain condition, the claim is remanded to afford a VA examiner the opportunity to clarify any diagnosis related to pleuritic chest pain, and if a diagnosis is not identified, then to determine if pain alone results in functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (if pain alone results in functional impairment, even if there is no identified underlying diagnosis, such pain can constitute a disability); see also Wait v. Wilkie, 33 Vet. App. 8 (2020) (to establish the presence of a disability pursuant to Saunders, there must be competent evidence specific to the claimant tending to show that his or her impairment rises to a level to affect earning capacity). Therefore, as it is unclear from the record whether the Veteran has a current disability related to his pleuritic chest pain claim, a remand for an additional VA examination is necessary. 2. Entitlement to service connection for heart condition is remanded. The Veteran attended a VA examination in February 2020 for an evaluation of his heart condition. The examination report reflects no diagnosis of a heart condition. However, the examiner noted that the June 2016 echocardiogram showed mild aortic and tricuspid regurgitation. The examiner then noted that the conditions of mild aortic and tricuspid regurgitation are of little significance as they do not produce symptoms, and he stated that the conditions are unrelated to the claimed condition of congestive heart failure. Therefore, the examiner concluded that no diagnosis of mild aortic and tricuspid regurgitation was warranted. A February 2018 echocardiogram showed mild concentric left ventricular hypertrophy and mild aortic root enlargement. In addition, a January 2017 private medical record lists coronary artery disease in the past medical history section. Given that there is evidence of a potential heart condition, the Board concludes that an additional VA examination and opinion are warranted to determine the nature and etiology of any heart condition. In addition, the Veteran has also alleged that he has a heart condition that is secondary to pleuritic chest pain. Thus, as a decision on the remanded issue of pleuritic chest pain could significantly impact a decision on the issue of service connection for heart condition, the issues are inextricably intertwined. Therefore, a remand of the claim for service connection for heart condition is required. 3. Entitlement to service connection for hypertension is remanded. 4. Entitlement to service connection for sleep apnea is remanded. 5. Entitlement to service connection for a digestive disorder, to include gastric ulcers, gastroenteritis, and GERD but excluding IBS, is remanded. 6. Entitlement to service connection for left foot neuropathy is remanded. 7. Entitlement to service connection for right foot neuropathy is remanded. 8. Entitlement to service connection for left shoulder degenerative joint disease is remanded. 9. Entitlement to service connection for neck condition is remanded. 10. Entitlement to service connection for chronic fatigue syndrome is remanded. 11. Entitlement to service connection for restless leg syndrome is remanded. 12. Entitlement to service connection for gout is remanded. 13. Entitlement to service connection for right kidney cyst is remanded. 14. Entitlement to service connection for urinary incontinence is remanded. 15. Entitlement to service connection for migraine headaches is remanded. 16. Entitlement to service connection for otitis media is remanded. The Board remanded these claims in October 2019 to obtain VA examinations and/or opinions as to the nature and etiology of the conditions. The Veteran attended VA examinations in February 2020 for the conditions in this section. The same VA examiner performed the examination for each of the conditions. The VA examiner then provided negative opinions as to whether each of the conditions were directly related to the Veteran’s service or whether each of the conditions were caused or aggravated by a service-connected disability. However, the opinions are inadequate for evaluation purposes, so an additional remand of all of these claims is necessary to obtain adequate opinions as to the etiology of the Veteran’s conditions in this section. Furthermore, the Veteran has alleged in part that his claims for service connection for gout, right kidney cyst, urinary incontinence, hypertension, and migraine headaches are secondary to a digestive disorder, excluding IBS. Thus, as a decision on the remanded issue of digestive disorder could significantly impact a decision on the issues of service connection for gout, right kidney cyst, urinary incontinence, hypertension, and/or migraine headaches, the issues are inextricably intertwined. Therefore, a remand of the claims for service connection for gout, right kidney cyst, urinary incontinence, hypertension, and migraine headaches is required. In addition, regarding the Veteran’s claim for service connection for hypertension, the Veteran has also alleged that his diagnosed hypertension is secondary to his sleep apnea. Thus, as a decision on the remanded issue of sleep apnea could significantly impact a decision on the issue of service connection for hypertension, the issues are inextricably intertwined. Therefore, a remand of the claim for service connection for hypertension is required. Regarding the Veteran’s claim for service connection for chronic fatigue syndrome, the Veteran has also alleged that he has chronic fatigue that is secondary to his sleep apnea and restless leg syndrome. Thus, as a decision on the remanded issues of sleep apnea and/or restless leg syndrome could significantly impact a decision on the issue of service connection for chronic fatigue syndrome, the issues are inextricably intertwined. Therefore, a remand of the claim for service connection for chronic fatigue syndrome is required. The matters are REMANDED for the following actions: 1. Obtain and associate with the Veteran’s electronic record VA treatment records from April 2018 to the present. Contact the Veteran and afford him the opportunity to identify or submit any pertinent evidence in support of his claims, to include records of any private treatment. Based on his response, attempt to procure copies of all records which have not been obtained from identified treatment sources. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e). 2. After completing the development requested in item 1, provide the Veteran an appropriate VA examination (or telehealth interview, if an in-person examination is not feasible), from a different VA examiner than the one who performed the February 2020 VA examination, to determine the nature, extent, and etiology of the Veteran’s hypertension, pleuritic chest pain, and heart condition claims. The electronic claims file must be made available to the examiner for review in connection with the examination. All indicated tests should be conducted, and the reports of any such studies incorporated into the examination reports to be associated with the claims file. After reviewing the claims file, the examiner should address the following: (a.) Hypertension i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is related or attributable to his military service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is caused by his service-connected COPD with frequent pneumonia and/or IBS? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected COPD with frequent pneumonia and/or IBS? If the Veteran’s hypertension has been aggravated by his service-connected COPD with frequent pneumonia or IBS, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. iv) If, and only if, it is determined that the Veteran’s sleep apnea and/or digestive disorder, other than IBS, is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is caused by his sleep apnea and/or digestive disorder, other than IBS? v) If, and only if, it is determined that the Veteran’s sleep apnea and/or digestive disorder, other than IBS, is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s hypertension is aggravated by (i.e., any increase in the severity beyond its natural progression) his sleep apnea and/or digestive disorder, other than IBS? If the Veteran’s hypertension has been aggravated by his sleep apnea and/or digestive disorder, other than IBS, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation.   (b.) Pleuritic Chest Pain i) Does the Veteran have a disability manifested by pleuritic chest pain or does the symptom of pleuritic chest pain cause any functional impairment of earning capacity? In addressing this question, the examiner is requested to consider the Veteran’s report of intermittent chest pain at the February 2020 VA examination and the February 2008 diagnosis of pleurisy. ii) If the Veteran has a disability manifested by pleuritic chest pain or any functional impairment from pleuritic chest pain, then is it at least as likely as not (50 percent or greater probability) that such is related or attributable to his military service? iii) For any disability manifested by pleuritic chest pain or any functional impairment from pleuritic chest pain, is it at least as likely as not (50 percent or greater probability) that such is caused by his service-connected COPD with frequent pneumonia? iv) For any disability manifested by pleuritic chest pain or any functional impairment from pleuritic chest pain, is it at least as likely as not (50 percent or greater probability) that such is aggravated (i.e., any increase in the severity beyond its natural progression) by his service-connected COPD with frequent pneumonia? If the Veteran’s disability manifested by pleuritic chest pain or any functional impairment from pleuritic chest pain has been aggravated by his service-connected COPD with frequent pneumonia, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. (c.) Heart Condition i) Does the Veteran have a diagnosis of any heart condition, excluding hypertension? In answering this question, the examiner is requested to consider the June 2016 echocardiogram showing mild aortic and tricuspid regurgitation, the January 2017 private medical record listing coronary artery disease in the past medical history section, and the February 2018 echocardiogram showing mild concentric left ventricular hypertrophy and mild aortic root enlargement. ii) For any diagnosed heart condition, excluding hypertension, is it at least as likely as not (50 percent or greater probability) that such is related or attributable to his military service? iii) If, and only if, it is determined that pleuritic chest pain is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed heart condition is caused by his pleuritic chest pain? iv) If, and only if, it is determined that pleuritic chest pain is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed heart condition is aggravated by (i.e., any increase in the severity beyond its natural progression) his pleuritic chest pain? If the Veteran’s diagnosed heart condition has been aggravated by pleuritic chest pain, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to all of the above questions, the medical professional is requested to consider the pertinent medical literature submitted by the Veteran in September 2020 regarding the Veteran’s heart condition. The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 3. After completing the development requested in item 1, obtain a medical opinion, from a different VA examiner than the one who provided the opinions in February 2020, for the Veteran’s sleep apnea, restless leg syndrome, and chronic fatigue syndrome claims. If the medical professional determines that an in-person examination (including via telehealth interview) is needed in order to answer the questions posed, then such should be scheduled. After reviewing the claims file, the medical professional(s) should address the following: (a.) Sleep Apnea i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea is related or attributable to his military service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea is caused by his service-connected COPD with frequent pneumonia and/or chronic sinusitis with allergic rhinitis? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected COPD with frequent pneumonia and/or chronic sinusitis with allergic rhinitis? If the Veteran’s sleep apnea has been aggravated by his service-connected COPD with frequent pneumonia and/or chronic sinusitis with allergic rhinitis, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to the above questions, the medical professional is requested to consider the pertinent medical literature submitted by the Veteran in March 2019 and September 2020 regarding the Veteran’s sleep apnea. The medical professional must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. (b.) Restless Leg Syndrome i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s restless leg syndrome or periodic limb movement is related or attributable to his military service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s restless leg syndrome or periodic limb movement is caused by his service-connected bilateral flat feet with degenerative arthritis? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s restless leg syndrome or periodic limb movement is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected bilateral flat feet with degenerative arthritis? If the Veteran’s restless leg syndrome or periodic limb movement has been aggravated by his service-connected bilateral flat feet with degenerative arthritis, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to the above questions, the medical professional is requested to consider the pertinent medical literature submitted by the Veteran in October 2020 regarding the Veteran’s restless leg syndrome. The medical professional must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. (c.) Chronic Fatigue Syndrome i) Does the Veteran have a diagnosis of chronic fatigue syndrome for VA purposes? In addressing this question, the medical professional is requested to consider the September 2005 diagnosis of other malaise and fatigue and the February 2020 VA examination report reflecting that the Veteran has had acute onset of debilitating fatigue severe enough to reduce daily activity level to less than 50 percent of the usual level for at least 6 months and 6 or more symptoms associated with the condition. If the Veteran does not have a diagnosis of chronic fatigue syndrome, the medical professional is requested to provide a discussion as to the Veteran’s other clinical conditions that are producing the symptoms of the Veteran’s chronic fatigue syndrome. ii) If chronic fatigue syndrome is diagnosed, is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed chronic fatigue syndrome is related or attributable to his military service? iii) If chronic fatigue syndrome is diagnosed, is it at least as likely as not (50 percent or greater probability) that the Veteran’s chronic fatigue syndrome is caused by his service-connected COPD with frequent pneumonia? iv) If chronic fatigue syndrome is diagnosed, is it at least as likely as not (50 percent or greater probability) that the Veteran’s chronic fatigue syndrome is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected COPD with frequent pneumonia? If the Veteran’s chronic fatigue syndrome has been aggravated by his service-connected COPD with frequent pneumonia, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. v) If, and only if, it is determined that the Veteran’s restless leg syndrome and/or sleep apnea is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed chronic fatigue syndrome is caused by his restless leg syndrome and/or sleep apnea? vi) If, and only if, it is determined that the Veteran’s restless leg syndrome and/or sleep apnea is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed chronic fatigue syndrome is aggravated by (i.e., any increase in the severity beyond its natural progression) his restless leg syndrome and/or sleep apnea? If the Veteran’s chronic fatigue syndrome has been aggravated by his restless leg syndrome or sleep apnea, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to the above questions, the medical professional is requested to consider the pertinent medical literature submitted by the Veteran in October 2020 regarding the Veteran’s chronic fatigue syndrome. The medical professional must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 4. After completing the development requested in item 1, obtain a medical opinion, from a different VA examiner than the one who provided the opinions in February 2020, for the Veteran’s digestive disorder, right kidney cyst, and urinary incontinence claims. If the medical professional determines that an in-person examination (including via telehealth interview) is needed in order to answer the questions posed, then such should be scheduled. After reviewing the claims file, the medical professional(s) should address the following: (a.) Digestive Disorder i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s digestive disorder, to include gastric ulcers, gastroenteritis, and GERD, but excluding IBS, is related or attributable to his military service? In addressing this question, the medical professional is requested to consider that a March 2014 VA examination reflects a diagnosis of gastric ulcer and that the Veteran stated in March 2014 and April 2014 statements that he was treated in August 1982 by a private physician, Dr. G.H., for bleeding ulcers. The Veteran indicated that Dr. G.H. died in 2010 and that his records have been destroyed and are unavailable. The Veteran is competent to report being treated in service for gastric ulcers. ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s digestive disorder is caused by his service-connected lumbar spine disability, to include the use of nonsteroidal anti-inflammatory drugs for his lumbar spine disability? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s digestive disorder is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected lumbar spine disability, to include the use of nonsteroidal anti-inflammatory drugs for his lumbar spine disability? If the Veteran’s digestive disorder has been aggravated by his service-connected lumbar spine disability, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to the above questions, the medical professional is requested to consider the pertinent medical literature submitted by the Veteran in March 2019, September 2020, and October 2020 regarding the Veteran’s digestive disorder. The medical professional must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. (b.) Right Kidney Cyst and Urinary Incontinence i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s right kidney cyst or urinary incontinence is related or attributable to his military service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s right kidney cyst or urinary incontinence is caused by his service-connected IBS? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s right kidney cyst or urinary incontinence is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected IBS? If the Veteran’s right kidney cyst or urinary incontinence has been aggravated by his service-connected IBS, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. iv) If, and only if, it is determined that the Veteran’s digestive disorder, other than IBS, is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s right kidney cyst or urinary incontinence is caused by his digestive disorder, other than IBS? v) If, and only if, it is determined that the Veteran’s digestive disorder, other than IBS, is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s right kidney cyst or urinary incontinence is aggravated by (i.e., any increase in the severity beyond its natural progression) his digestive disorder, other than IBS? If the Veteran’s right kidney cyst or urinary incontinence has been aggravated by his digestive disorder, other than IBS, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to the above questions, the medical professional is requested to consider the pertinent medical literature submitted by the Veteran in October 2020 regarding the Veteran’s urinary incontinence. The medical professional must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 5. After completing the development requested in item 1, obtain a medical opinion, from a different VA examiner than the one who provided the opinions in February 2020, for the Veteran’s bilateral foot neuropathy, left shoulder, neck, and gout claims. If the medical professional determines that an in-person examination (including via telehealth interview) is needed in order to answer the questions posed, then such should be scheduled. After reviewing the claims file, the medical professional(s) should address the following: (a.) Bilateral Foot Neuropathy i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left and right foot neuropathy (diagnosed as bilateral tarsal tunnel syndrome) is related or attributable to his military service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left and right foot neuropathy (diagnosed as bilateral tarsal tunnel syndrome) is caused by his service-connected lumbar spine disability? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left and right foot neuropathy (diagnosed as bilateral tarsal tunnel syndrome) is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected lumbar spine disability? If the Veteran’s left and right foot neuropathy (diagnosed as bilateral tarsal tunnel syndrome) has been aggravated by his service-connected lumbar spine disability, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to the above questions, the medical professional is requested to consider the pertinent medical literature submitted by the Veteran in October 2020 regarding the Veteran’s neuropathy. The medical professional must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation.   (b.) Left Shoulder Degenerative Arthritis i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left shoulder degenerative arthritis is related or attributable to his military service, to include the December 1980 fall down steps in service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left shoulder degenerative arthritis is caused by his service-connected lumbar spine disability? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s left shoulder degenerative arthritis is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected lumbar spine disability? If the Veteran’s left shoulder degenerative arthritis has been aggravated by his service-connected lumbar spine disability, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. The medical professional must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. (c.) Neck Condition i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s neck condition is related or attributable to his military service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s neck condition is caused by his service-connected lumbar spine disability and/or his IBS? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s neck condition is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected lumbar spine disability and/or his IBS? If the Veteran’s neck condition has been aggravated by his service-connected lumbar spine disability and/or IBS, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. The medical professional must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. (d) Gout i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s gout is related or attributable to his military service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s gout is caused by his service-connected IBS? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s gout is aggravated by (i.e., any increase in the severity beyond its natural progression) his service-connected IBS? If the Veteran’s gout has been aggravated by his service-connected IBS, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. iv) If, and only if, it is determined that the Veteran’s digestive disorder, other than IBS, is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s gout is caused by his digestive disorder, other than IBS? v) If, and only if, it is determined that the Veteran’s digestive disorder, other than IBS, is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s gout is aggravated by (i.e., any increase in the severity beyond its natural progression) his digestive disorder, other than IBS? If the Veteran’s gout has been aggravated by his digestive disorder, other than IBS, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to the above questions, the medical professional is requested to consider the pertinent medical literature submitted by the Veteran in and September 2020 and October 2020 regarding the Veteran’s gout. The medical professional must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 6. After completing the development requested in item 1, provide the Veteran an appropriate VA examination (or telehealth interview, if an in-person examination is not feasible), from a different VA examiner than the one who performed the February 2020 VA examination, to determine the nature, extent, and etiology of the Veteran’s migraine headaches and otitis media. The electronic claims file must be made available to the examiner for review in connection with the examination. All indicated tests should be conducted, and the reports of any such studies incorporated into the examination reports to be associated with the claims file. After reviewing the claims file, the examiner should address the following: (a.) Migraine Headaches i) Provide a diagnosis of any headache condition. In addressing this, the examiner is requested to consider the February 2015 diagnosis of headache in a private medical record and the June 2015 diagnosis of headache in a VA treatment record. ii) For any diagnosed headache condition, including the diagnoses of headache in February 2015 and June 2015, is it at least as likely as not (50 percent or greater probability) that such is related or attributable to his military service? iii) For any diagnosed headache condition, including the diagnoses of headache in February 2015 and June 2015, is it at least as likely as not (50 percent or greater probability) that such is caused by his service-connected COPD with frequent pneumonia and/or chronic sinusitis with allergic rhinitis? iv) For any diagnosed headache condition, including the diagnoses of headache in February 2015 and June 2015, is it at least as likely as not (50 percent or greater probability) that such is aggravated (i.e., any increase in the severity beyond its natural progression) by his service-connected COPD with frequent pneumonia and/or chronic sinusitis with allergic rhinitis? If the Veteran’s headache condition has been aggravated by his service-connected COPD with frequent pneumonia and/or chronic sinusitis with allergic rhinitis, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. v) If, and only if, it is determined that the Veteran’s digestive disorder, other than IBS, is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s headache condition is caused by his digestive disorder, other than IBS? vi) If, and only if, it is determined that the Veteran’s digestive disorder, other than IBS, is service-connected, is it at least as likely as not (50 percent or greater probability) that the Veteran’s headache condition is aggravated by (i.e., any increase in the severity beyond its natural progression) his digestive disorder, other than IBS? If the Veteran’s headache condition has been aggravated by his digestive disorder, other than IBS, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to the above questions, the examiner is requested to consider the pertinent medical literature submitted by the Veteran in October 2020 regarding the Veteran’s headache condition. The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. (b.) Otitis Media i) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s otitis media is related or attributable to his military service? ii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s otitis media is caused by his service-connected COPD with frequent pneumonia or sinusitis with allergic rhinitis? iii) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s otitis media is aggravated by (i.e., any increase in the severity beyond its natural progression) his COPD with frequent pneumonia or sinusitis with allergic rhinitis? If the Veteran’s otitis media has been aggravated by his service-connected COPD with frequent pneumonia or sinusitis with allergic rhinitis, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements as to the nature, severity, and frequency of his observable symptoms over time. In responding to the above questions, the examiner is requested to consider the pertinent medical literature submitted by the Veteran in October 2020 regarding the Veteran’s otitis media. The examiner must fully explain the rationale for all opinions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the medical professional cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Breitbach, 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.