Citation Nr: 21023957 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 15-07 284 DATE: April 21, 2021 ORDER Entitlement to service connection for hemorrhoids is denied. REMANDED Entitlement to service connection for flat feet is remanded. Entitlement to service connection for acid reflux is remanded. Entitlement to service connection for hepatitis C is remanded. Entitlement to service connection for asthma is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. FINDING OF FACT The preponderance of the evidence is against the appellant’s hemorrhoids having developed during active service, or being otherwise related to active service. CONCLUSION OF LAW The criteria for entitlement to service connection for hemorrhoids are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant served on active duty in the United States Marine Corps from June 1976 to June 1979. He had additional service in the United States Marine Corps Reserve with periods of active duty for training (ADT) and inactive duty for training (IDT) during the period. He was discharged from the United States Marine Corps Reserve under other than honorable conditions in August 1984. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for these claims. This decision was appealed in 2 separate notices of disagreement (NOD) received by VA in May 2014. A Statement of the Case (SOC) was issued by VA in January 2015. VA received the appellant’s Substantive Appeal (Form 9) in February 2015, perfecting the appeal and requesting a hearing before the Board. The appellant appeared before the undersigned Veterans Law Judge for a videoconference hearing in August 2018. A transcript of that hearing has been added to the record. This case was remanded by the Board in August 2019 for additional development. More recently, these claims were again remanded by the Board in a July 2020 decision so that new VA examinations and medical opinions could be obtained. Supplemental Statements of the Case (SSOC) were issued by VA in May 2020 and February 2021. 1. Entitlement to service connection for hemorrhoids is denied. The appellant contends that his current hemorrhoids developed while he was on active duty with the United States Marine Corps. He asserts that he developed hemorrhoids in the weeks before his separation examination and that they left him incapacitated at that time and unable to complete his separation examination. See Appellant’s August 2018 hearing transcript. After a review of the evidence of record, the Board finds that the preponderance of the evidence is against the appellant’s current hemorrhoids having developed during active service, or otherwise being related to his active service. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The appellant’s service treatment records show him having several bouts of gastrointestinal issues during his period of active service. In June 1976, shortly after his induction, he was prescribed Mylanta for stomach cramping and constipation with the examiner opining that the appellant’s symptoms were likely an adjustment to the food being served in basic training. In December 1976 he was again prescribed Mylanta for another bout of stomach pain, cramps, and nausea. The appellant then went untreated for gastrointestinal issues in service until January 1979, at which point he was treated for diarrhea, bloody stool, pain in his anus, and stomach cramps, all of which the examiner attributed to a viral infection. By February 1979, he seems to have been free of symptoms, as he did not offer complaints relating to his digestive system at his next appointment. At both his entrance and separation examination, the appellant’s anus and rectum were examined and found to have no abnormality and no sign of hemorrhoids. Records from the appellant’s Reserve service indicates that he was potentially exposed to Hepatitis A through a food borne vector during a period of he was on ADT. He was given prophylactic treatment in the form of gamma globulin. A subsequent medical examination at the end of his period of ADT found him to be free from disease and or other physical defects resulting from his period of ADT. Reserve treatment records do not include any complaints or treatment for hemorrhoids. The appellant’s VA treatment notes first record him as having complained of hemorrhoids at a July 2014 VA treatment appointment. Subsequent records show continued treatment for the disability through to the present, with the appellant having been prescribed a cream meant to relieve symptoms. Nothing in these treatment records indicates that the disability began during the appellant’s service or is otherwise connected to an event, injury, or disease contracted during his period of active service. The appellant’s hemorrhoids were examined at a December 2020 VA examination. At the time, he was observed to be asymptomatic, with no apparent hemorrhoids on examination. The examiner noted that the appellant reported having been diagnosed with hemorrhoids around the time of a colonoscopy he underwent in 2013. On the question of whether the appellant’s hemorrhoids began during his active service, the examiner opined that it was less likely than not that the appellant had hemorrhoids during his military service. The examiner reasoned that when the appellant was examined for his diarrhea and rectal pain in January 1979, he was not observed to have any hemorrhoids. The examiner also seemed to afford significant weight to the findings of the separation examination, which did examine the appellant’s anus and rectum and found no evidence of any abnormality such as hemorrhoids. The Board affords the December 2020 VA examination significant probative weight, as the opinion was offered by a clinician, a medical doctor, who was competent to render an opinion, due to training and experience. See Nieves - Rodriguez v. Peake, 22 Vet. App. 295 (U.S. 2008). The clinician based the opinion on a review of the record on appeal as well as a consideration of the appellant’s medical history. After a review of the evidence of record, the Board finds that while the evidence at least as likely as not shows the appellant has a current disability, and had an in-service occurrence of symptoms which could be consistent with a hemorrhoid disability, the preponderance of the evidence is against finding the appellant’s current disability is related to, or was incurred during, active service. In reaching this finding, the Board has afforded significant probative weight to the December 2020 medical opinion. The appellant’s contention is that his hemorrhoids developed about a week before his separation examination, and that he was unable to complete the examination. However, the appellant’s separation examination is of record and shows no evidence, after an examination of the appellant’s rectum and anus, of any abnormality, to include hemorrhoids. Five months prior to the separation examination, when the appellant had developed diarrhea with rectal pain, he was examined and no notation of any hemorrhoids was noted. The medical examiner’s opinion is based on these findings which ruled out hemorrhoids at the time the appellant reported that they developed in service. The Board finds this rationale to be adequate to support the December 2020 medical examiner’s opinion. The Board recognizes that the appellant did at least as likely as not experience symptoms, such as rectal pain and bleeding, which could be consistent with hemorrhoids and that the appellant is competent to report these signs and symptoms that he has personally experienced. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The record does not contain any evidence though that the appellant is competent, whether by training, knowledge, or experience, to attribute those symptoms, experienced more than 30 years prior, specifically to a diagnosis of hemorrhoids. Moreover, even if he were competent to diagnose himself as having had hemorrhoids over 30 years ago based on the symptoms he experienced, which the Board notes are not exclusive to a diagnosis of hemorrhoids, he is not competent, whether by training, knowledge, or experience, to offer an opinion regarding whether his current hemorrhoid disability is related to hemorrhoids experienced more than 30 years prior. Even then, the Board affords greater probative weight to the contemporaneous evidence of record rather than to the appellant’s remote recollections regarding when he experienced the symptoms he described. The appellant did not give definitive testimony regarding the timeline of symptoms, noting that he could not recall whether he developed hemorrhoids before or after his separation examination, and how far before his separation from active service the reported symptoms manifested. He estimated maybe a week before his separation but acknowledged that the passage of time affected his memory of the incident in question. Symptoms he describes appear consistent with those observed in January 1979, a few months prior to his separation, in which he had rectal bleeding and diarrhea due to a viral infection, with no signs of hemorrhoids. The separation physical also included an examination of the appellant’s rectum and anus and found no evidence of any abnormality. These were contemporaneous records produced after observation of the appellant in a clinical setting, and as such, the Board affords them more probative weight than the appellant’s unsure and remote recollections. As such, the Board affords greater probative weight to the December 2020 VA medical opinion than to the appellant’s not competent lay opinion, which is itself based only on unsure remote recollections. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). The Board has considered the medical opinion received in November 2018 which did opine that the appellant’s hemorrhoids did at least as likely as not have their onset during his active service. However, as mentioned in the Board’s prior March 2020 decision, this medical opinion is inadequate, as the opinion is speculative and conclusory in nature, lacking an adequate rationale or any explanation for the opinion offered. As such, the Board finds it is of low probative value. See Nieves - Rodriguez v. Peake, 22 Vet. App. 295 (U.S. 2008) (most of the probative value of a medical opinion comes from its reasoning); see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Considering all this, the Board finds that the preponderance of the evidence is against the appellant’s current hemorrhoids being related to any in-service symptoms of bleeding and rectal pain due to viral infection and bouts of diarrhea, or any other event in service, or having been incurred during active service. As the preponderance of the evidence is against there being a nexus between the current disability and an in-service incurrence of that disability, or any relationship between the current disability and the in-service event, the Board concludes that the criteria for entitlement to service connection for hemorrhoids are not met. 38 C.F.R. § 3.303. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is inapplicable. 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for flat feet is remanded. The appellant contends that his flat feet were aggravated during active duty by running and marching in boots on hard surfaces for long periods of time. See August 3, 2018 Transcript of Hearing. At the appellant’s April 1976 entrance examination, clinical evaluation of the appellant’s feet was abnormal, with a notation of “PP.” See April 1976 Report of Medical Examination. The appellant’s service treatment records show that he developed blisters and callouses on his right foot during active service. Additionally, he reports he developed symptoms of pain in both his feet during this time, pain which has persisted since service. The Board previously remanded this claim in July 2020 to obtain an addendum medical opinion which addressed whether the appellant’s disability was aggravated during active service, with the Board noting the condition noted at entrance into active service. In December 2020 and January 2021 VA medical opinions, the examiner found that there was not at least as likely as not an aggravation of the appellant’s disability during active service as the condition was mild and asymptomatic in April 1976 at his induction, and mild and asymptomatic at the time of his VA examination in December 2020. However, the Board finds this rationale inadequate, as it does not address the findings made at the appellant’s February 2014 VA examination and at a December 2018 VA examination which both showed current symptoms. At the appellant’s February 2014 VA examination, the appellant reported a worsening of the flat foot condition, which he noted had been with him since birth. He indicated that the condition leads to his feet swelling up and the development of calluses. He was examined and found to have pain on manipulation in both feet, characteristic calluses on both feet, plantar tenderness on both feet, and issues with alignment and deformity. At the appellant’s December 2018 VA examination, he was observed with additional disability of the feet diagnosed as plantar fasciitis and arthritis. He reported regularly wearing prescription insoles to alleviate symptoms, and reported that symptoms of pain caused difficulty standing. As the January 2020 medical opinion failed to address these findings and symptoms, which are “current” in relation to this claim, as they were all made or found since this claim was initially filed, the Board finds that an additional medical opinion is necessary prior to adjudicating this claim which addresses these findings. Addressing these findings is necessary, as the January 2021 VA medical opinion is based entirely on the appellant being asymptomatic years later, indicating no worsening of the underlying condition, which seems to conflict with the findings of these other VA examinations. Additionally, the Board notes that the January 2021 VA medical opinion also failed to address the treatment the appellant received on his feet to treat blisters and calluses during his period of active duty. On remand the examiner should address whether this treatment was due to the preexisting pes planus, and if so, whether it represents a worsening of the appellant’s disability. 2. Entitlement to service connection for acid reflux is remanded. The appellant contends that he developed acid reflux during boot camp. He asserts that he was forced to eat too quickly and was unable to properly digest his food, which resulted in a burning sensation through the course of the day. See August 3, 2018 Transcript of Hearing. The Board previously remanded this claim for further development, to include obtaining a new VA examination and medical opinion, which was completed in December 2020. In the December 2020 medial opinion, the examiner found that the appellant’s current gastroesophageal reflux disease (GERD) was not at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the appellant’s GERD was not due to any “remote history of acute, but self-limiting gastroenteritis he may have experienced remotely in military service.” The examiner explained that acute gastroenteritis does not cause GERD and would have resolved decades prior with appropriate treatment. In the “Evidence Review” portion of the medical opinion, the examiner seems to have only considered a January 1979 service treatment record in which the appellant was treated for acute abdominal cramps, diarrhea, and anal pain, all of which were deemed viral symptoms, in reaching the above conclusion. No mention or discussion was provided regarding the appellant’s multiple incidences of treatment for abdominal distress in June and December 1976. The Board specifically notes that the June 1976 treatment record attributed the appellant’s symptoms to adjustments to the food provided for service members who were attending basic training. These records appear relevant to the question of whether the appellant developed his current GERD while on active duty, and as they were not discussed by the examiner, the Board finds that remand for an addendum opinion is warranted for this claim. 3. Entitlement to service connection for hepatitis C is remanded. The appellant contends that he contracted hepatitis C from inoculations he received during active duty. He asserts that the same “air gun” was used to inoculate hundreds of service members, and that the VA physician who diagnosed him with hepatitis C told him this was possible he was infected at that time. Alternatively, the appellant contends that he contracted hepatitis C during an in-service oral surgery, during which he was “bleeding kind of bad.” See August 3, 2018 Transcript of Hearing. The appellant’s service treatment records are negative for complaints, observations, or treatment for hepatitis C, although he was given prophylactic treatment during a period of ADT in August 1981 due to potential food exposure to hepatitis A. VA treatment records indicate that he received a temporary crown and dental implants in August and October 1977. According to his VA treatment records, the appellant was diagnosed with hepatitis C in 2007, and has received treatment for this since. In a December 2020 VA medical opinion, the examiner opined that the appellant’s hepatitis C was not at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that this was based on a lack of service treatment records documenting a hepatitis C infection or of the appellant engaging in risk factors associated with hepatitis C while he was in military service. No further rationale was provided. The Board finds the rationale provided in the December 2020 VA medical opinion is inadequate, as it relies entirely on the lack of in-service diagnosis or treatment for hepatitis C, with no explanation of why the lack of an in-service diagnosis is dispositive. See Dalton v. Nicholson, 12 Vet. App. 23 (2007) (holding that the lack of documentary evidence during or after service cannot be the sole basis for an opinion against the claim); Buchannan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (addressing lay evidence as potentially competent to support presence of disability even when not corroborated by contemporaneous medical evidence). No consideration was given to the appellant’s testimony that he may have contracted the disease during an in-service oral surgery or during mass inoculations prior to an overseas deployment. As such, an addendum opinion is necessary to address the appellant’s lay contentions. The addendum opinion should also provide a rationale as to why a lack of in-service treatment or diagnosis is, in and of itself, evidence that the appellant’s disability was not incurred during active service. Additionally, the Board notes that the December 2020 VA medical examination accompanying the medical opinion indicates that the appellant’s risk factors for hepatitis C exposure were considered “unknown.” This contradicts part of the rationale for the December 2020 medical opinion, that the appellant had no known risk factors for hepatitis C exposure. Further, the Board notes that this is also factually inaccurate, as the appellant’s treatment records note multiple gonorrhea infections in August 1981 and August 1983, and a positive test for cocaine in July 1983. The appellant was a member of the United States Marine Corps Reserves at the time. VA’s Hepatitis, Cirrhosis and Other Liver Conditions Disability Benefits Questionnaire (DBQ) lists both “high risk sexual activity” and “intravenous drug use or intranasal cocaine use” as risk factors for contracting hepatitis C. These discrepancies should be addressed on remand. 4. Entitlement to service connection for asthma is remanded. The appellant contends that he experienced shortness of breath while running during active duty. He contends that he went to sickbay and was told he had “bronchitis asthma.” See August 3, 2018 Transcript of Hearing. At the appellant’s April 1976 entrance examination, clinical evaluation of the appellant’s lungs and chest was normal. No defects or diagnoses were noted regarding his lungs or chest. The appellant reported he was in good health and did not endorse ever having been diagnosed with asthma. He did report a history of hay fever with the physician noted as “summer allergic rhinitis.” The appellant was found to be qualified for enlistment. A September 1977 entry in the appellant’s service treatment records noted complaints of a sore throat, non-productive cough, and shortness of breath for 2 to 3 days. At the time, the appellant was noted to have had a history of bronchial asthma, and he was diagnosed at the time with an upper respiratory infection. An October 1977 entry in his service treatment records also diagnosed upper respiratory infection after reports of wheezing, a sore throat, runny nose, and general malaise. At his February 2014 VA examination, the appellant reported that he was diagnosed with “broncho asthma” as a baby. He reported current symptoms of wheezing and shortness of breath. VA treatment records from this period show the appellant using an inhaler. The examiner diagnosed the appellant with asthma. As set forth above, the appellant’s lungs and chest were normal at his entrance examination, and no defects or diagnoses were noted regarding his lungs or chest. Therefore, the appellant is presumed to have been in sound condition at the time he entered service. 38 U.S.C. §§ 1111, 1137. When a condition is not noted on entry into service, the burden falls on VA to rebut the presumption of soundness by clear and unmistakable evidence that a veteran’s disability was both preexisting and no aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In its July 2020 remand of this claim, the Board ordered the RO to obtain a medical examination which addressed whether the appellant’s asthma clearly and unmistakably pre-existed his entry into active service based on the in-service notations of pre-existing asthma and the appellant’s reports of having had asthma since childhood at the February 2014 VA medical examination. The examiner was asked specifically to opine whether the appellant’s disability clearly and unmistakably pre-dated his active service. In a December 2020 medical opinion, the examiner noted on the DBQ that the appellant had never been diagnosed with a respiratory disability, which the Board notes is factually inaccurate considering the appellant’s VA treatment records and the prior February 2014 VA examination. More importantly though, in rendering an opinion, the examiner failed to answer the questions posed by the Board in its March 2020 decision. The examiner opined the appellant’s current disability was not at least as likely as not incurred during, or otherwise related to, active service, because asthma was not noted on his entrance examination and because he was not diagnosed with asthma during his military service, as noted on his military separation form. The Board finds this opinion inadequate for several reasons. First, the medical opinion does not address the first question the Board asked, which was whether, after reviewing all the evidence of record, the appellant’s asthma clearly and unmistakably pre-existed his period of active service. Two pieces of evidence, an in-service report of the appellant having previously had bronchial asthma, along with his reports at his February 2014 VA examination that he was diagnosed with asthma as a small child were raised by the Board and were not addressed by the December 2020 VA medical opinion. Even if the opinion were treated as having answered the above question in the negative, that the appellant’s asthma did not clearly and unmistakably pre-exist his period of active service, the opinion on direct causation is inadequate. Essentially, the rationale is that the appellant’s records do not contain a diagnosis of asthma in-service, and as such, it is not at least as likely as not that the condition was incurred in or otherwise related to the period of active service. This rationale is inadequate as it relies entirely on the lack of contemporaneous medical evidence without explaining why the lack of an in-service diagnosis is dispositive in this case. See Dalton v. Nicholson, 12 Vet. App. 23 (2007) (holding that the lack of documentary evidence during or after service cannot be the sole basis for an opinion against the claim); Buchannan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (addressing lay evidence as potentially competent to support presence of disability even when not corroborated by contemporaneous medical evidence). On remand, the examiner must offer an opinion as to whether the current disability, based on the in-service mention of bronchial asthma, and the appellant’s 2014 acknowledgement that he has was diagnosed with asthma in childhood, clearly and unmistakably pre-existed the appellant’s active service. If so, the examiner should then opine whether it was clearly and unmistakably not aggravated beyond its normal progression during active service. If the condition is not found to have clearly and unmistakably pre-existed active service, the examiner should opine whether it was at least as likely as not incurred in service, or is otherwise related o service. The examiner must provide an adequate rationale that addresses the appellant’s contentions regarding developing symptoms of asthma, such as shortness of breath on exertion and wheezing, which are documented in the appellant’s service treatment records, while on active service. 5. Entitlement to service connection for obstructive sleep apnea is remanded. The appellant contends that he experienced sleep apnea during active service. Specifically, at his August 2018 Board hearing, he testified that his girlfriend at the time of his active service and his son both told him that he snored loudly when he slept and it was his belief that those symptom were indicative of sleep apnea. See August 3, 2018 Transcript of Hearing. The appellant’s service treatment records are negative for findings of sleep apnea, complaints of sleep apnea symptoms, or other sleep-related symptomatology. In December 2007, the appellant underwent a sleep study through the VA which diagnosed him with primary snoring, but found that the appellant did not have any sleep apnea. It wasn’t until a subsequent sleep study through the VA in August 2014 that the appellant was diagnosed with mild obstructive sleep apnea. The July 2020 Board decision remanded this claim to obtain a VA examination and medical opinion regarding the etiology of the appellant’s current sleep apnea. In its remand directives, the Board ordered that the examiner consider the appellant’s hearing testimony to the effect that while on active duty, his girlfriend told him that he snored. After examining the appellant and reviewing the claims folder, the examiner opined that it was less likely than not that the claimed sleep apnea was incurred in or caused by the claimed in-service injury, event, or illness. As a rationale for this opinion, the examiner offered that the current sleep apnea was not “due to any remote military incidents, as military incidents do not cause OSA.” The examiner further reasoned that the appellant was never diagnosed with sleep apnea while in military service. No mention or discussion of the appellant’s contentions regarding his having developed symptoms of snoring in service were discussed. As the examiner did not address the appellant’s contentions, as ordered by the Board, the Board finds that the December 2020 VA medical opinion is inadequate for purposes of resolving this claim. Additionally, the Board finds that the rationale, which amounts to an argument that the condition was not diagnosed in service is inadequate, as it relies on an absence of contemporaneous medical evidence, without explaining why the lack of an in-service diagnosis is dispositive in this case, and does not address the lay evidence offered by the appellant. See Dalton v. Nicholson, 12 Vet. App. 23 (2007) (holding that the lack of documentary evidence during or after service cannot be the sole basis for an opinion against the claim); Buchannan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (addressing lay evidence as potentially competent to support presence of disability even when not corroborated by contemporaneous medical evidence). On remand, the examiner should be reminded that service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician which answers the following: Did the appellant’s pes planus, which existed prior to service and was noted on entry into active service, at least as likely as not increase in severity during service? If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? The examiner must address the appellant’s in-service treatment for symptoms affecting his feet such as his developing of a blister and callus on his right foot and his treatment for ingrown toenails. The examiner must also address the findings of the March 2014 and December 2018 VA examinations which found additional disability of the feet and noted that the current disability was not “asymptomatic” during the entire from when the appellant filed his initial claim for service connection. The examiner must also address the appellant’s reports of developing pain due to frequent running and marching while on active service. Provide a rationale to support the opinion. In providing the requested opinion, consider the appellant’s description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the appellant’s reported symptoms in service and thereafter represented the onset of any current foot disability, this should be noted. Stated another way, do the appellant’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the appellant’s reports generally inconsistent with medical knowledge or implausible? 2. Obtain an addendum opinion from an appropriate clinician that answers the following: Did the appellant’s current GERD at least as likely as not develop while he was in active service? Is the appellant’s current GERD at least as likely as not related to his reports of having to eat his food extremely quickly while in basic training, which he has testified led to a burning sensation in his chest through the day? The examiner must address the appellant’s lay statements and consider them in conjunction with his treatment in June and December 1976 for abdominal distress, which the in-service examiner related to the appellant’s adjustments to the food being served during basic training. Provide a rationale to support the opinion. In providing the requested opinion, consider the appellant’s description of his in-service symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the appellant’s reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the appellant’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the appellant’s reports generally inconsistent with medical knowledge or implausible? 3. Obtain an addendum medical opinion from an appropriate clinician that answers the following? Did the appellant at least as likely as not contract hepatitis C during his period of active service, or during a period of active duty for training? The examiner must discuss both the appellant’s recorded risk factors, to include oral surgery, intravenous or intranasal drug use, and high risk sexual activity which resulted in contraction of an STD, and his lay reports of having received inoculations before a deployment in which the same equipment was being used on everyone. Provide a rationale to support the opinion. In providing the requested opinion, consider the appellant’s description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the appellant’s reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the appellant’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the appellant’s reports generally inconsistent with medical knowledge or implausible? 4. Obtain an addendum opinion from an appropriate clinician regarding the appellant’s asthma that answers the following: Did the appellant’s currently diagnosed asthma clearly and unmistakably preexist his active service? In providing this opinion, the examiner must discuss the relevant evidence of record, including the appellant’s September 1977 service treatment note which indicates a history of bronchial asthma and the appellant’s report to the February 2014 VA examiner that he was diagnosed with asthma as a baby. If the examiner determines that the appellant’s current asthma clearly and unmistakably preexisted service, the examiner should answer the following: Was the appellant’s asthma clearly and unmistakably not aggravated (non-temporary increase in severity) by service and if so, was any increase in severity was clearly and unmistakably (undebatable) due to its natural progress? In providing the requested rationale, the clinician should consider the appellant’s reports that he experienced shortness of breath while running during active duty, and his service treatment records showing reports of and treatment for shortness of breath. If the answer regarding preexistence is that the appellant’s disability did not clearly and unmistakably preexist active service, the examiner should answer the following: Did the appellant’s asthma at least as likely as not have its inception during the appellant’s period of active duty, or is it otherwise causally related to an in-service injury or disease, to include the in-service reports and treatment for shortness of breath? Provide a rationale to support the opinion. The examiner’s opinion must not be based entirely on the absence of contemporaneous medical records showing a diagnosis of asthma. In providing the requested opinion, consider the appellant’s description of his in-service symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the appellant’s reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the appellant’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the appellant’s reports generally inconsistent with medical knowledge or implausible? 5. Obtain an addendum opinion from an appropriate clinician regarding the appellant’s sleep apnea which answers the following: Did the appellant’s current sleep apnea at least as likely as not have its inception during the appellant’s period of active duty, or is it otherwise causally related to an in-service injury or disease? The examiner must address the appellant’s lay contentions that he started snoring while on active duty. Provide a rationale to support the opinion. The examiner’s opinion must not be based entirely on the absence of contemporaneous medical records showing a diagnosis of sleep apnea while on active duty. In providing the requested opinion, consider the appellant’s description of his in-service symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the appellant’s reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the appellant’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the appellant’s reports generally inconsistent with medical knowledge or implausible? K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Kleponis, 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.