Citation Nr: 21024086 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 15-06 305A DATE: April 22, 2021 ORDER Entitlement to service connection for a heart disorder is denied. Entitlement to service connection for an acquired psychiatric disorder, to include dysthymic disorder, is denied. Entitlement to service connection for obstructive sleep apnea (OSA) is denied. Entitlement to service connection for degenerative joint disease, claimed as degenerative bone disease, is denied. REMANDED Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran has a heart disorder due to an in-service event, injury, or disease. 2. The preponderance of the evidence fails to establish that the Veteran has an acquired psychiatric disorder, to include dysthymic disorder, that is etiologically related to service or to a service-connected disability. 3. The preponderance of the evidence is against finding that the Veteran has OSA due to an in-service event, injury, or disease. 4. The preponderance of the evidence is against finding that the Veteran has degenerative joint disease due to an in-service event, injury, or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a heart disorder have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include as secondary to the Veteran’s service-connected migraine headaches, have not been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for entitlement to service connection for OSA have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for degenerative joint disease have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1991 to October 1991, October 1991 to September 1992, and July 1979 to April 1980. The Veteran also served in the Army National Guard. This issue comes before the Board of Veterans’ Appeals (Board) on appeal from January 2014 and February 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Offices (RO). In November 2017, the Veteran testified at a hearing before a Veterans Law Judge of the Board who is no longer active. A transcript of the hearing is associated with the record. In March 2018, the Veteran was given the opportunity to request another hearing, which she declined. Therefore, the Board will proceed with adjudication of the Veteran’s claims. This case was previously before the Board in July 2018. The Veteran’s claims were remanded for additional development. The case is now again before the Board for further appellate action. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may be granted on a secondary basis where the evidence shows (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when: (1) the weight of the evidence supports the claim, or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a heart disorder is denied. The Veteran contends that she has a heart disorder that was incurred during her active service. A September 1993 rating decision denied a service connection claim for a heart condition. A June 2001 rating decision denied service connection for a heart condition. A January 2014 rating decision denied a service connection claim for a heart condition (now claimed as heart arrhythmia), as new and material evidence was not submitted. In July 2018, the Board reopened the service connection claim for a heart condition and remanded the claim for a VA examination. Turning to the evidence, a July 1991 report of medical history documented the Veteran’s report that she had heart trouble and pain or pressure in the chest but did not experience palpitation or a pounding heart. A November 1991 service treatment record reported that the Veteran experienced sharp pain in the chest and was diagnosed with costochondritis. Costochondritis is an inflammation of the cartilaginous junction between a rib or ribs and the sternum. See Dorland's Illustrated Medical Dictionary, 423 (32nd ed. 2012). A June 1993 VA general medical examination reported that no heart condition or high blood pressure was found. A June 2004 VA stress test report indicated that the Veteran had no arrhythmias and her heart rate response was normal. An April 2011 private chest x-ray showed normal heart size and pulmonary vascularity with no significant abnormalities. An August 2012 private chest x-ray indicated the Veteran’s heart was normal in size. In March 2013, the Veteran submitted an authorization to release records in which she reported that she had experienced chest pain since 2007. The Veteran was provided a VA-contracted heart conditions examination in June 2019. The Veteran reported that she started having cardiac problems in the last 10 years or so. She reported having a rapid heart rate and shortness of breath. The examiner concluded that there was no objective evidence on examination to support any diagnosis at this time. He reported that the Veteran’s ejection fraction was 60-65 percent and completely within normal limits, which he indicated was self-explanatory regarding her cardiac status. The examiner opined that the Veteran’s heart condition was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. As rationale, the examiner explained that the Veteran does not currently have a cardiac condition. She had normal work ups in 2011 and 2012 and currently has a normal echocardiogram. He noted that she was diagnosed with costochondritis in November 1991. As previously described, a July 1991 report of medical history documented the Veteran’s report that she had heart trouble and pain or pressure in the chest but did not experience palpitation or a pounding heart. However, four months later, a November 1991 service treatment record reported that the Veteran was diagnosed with costochondritis for her sharp pain in the chest. A June 1993 VA general medical examination, conducted less than a year after the Veteran was discharged from active service in September 1992, reported that no heart condition or high blood pressure was found. While the Veteran believes she has a heart disorder that is related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. The issue is medically complex and requires specialized knowledge and experience. Jandreau, 492 F.3d at 1377 n.4 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide an etiology opinion on this issue. Consequently, the Board gives more probative weight to the June 2019 examination report and opinion. After reviewing the Veteran’s claims file, the June 2019 examiner opined that the Veteran’s heart disorder was less likely than not incurred in or caused by an in-service injury, event, or illness, as the examiner explained that the Veteran does not currently have a cardiac condition. She had normal work ups in 2011 and 2012 and currently has a normal echocardiogram. Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran’s claim for service connection for a heart disorder. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service connection has not been established and the Veteran’s claim for a heart disorder must be denied. 2. Entitlement to service connection for an acquired psychiatric disorder, to include dysthymic disorder, is denied. The Veteran contends that she has an acquired psychiatric disorder, to include dysthymic disorder, that is related to in-service stressors, as well as her service-connected migraine headaches. A September 1993 rating decision denied a service connection claim for stress. A June 2001 rating decision denied service connection for posttraumatic stress disorder (PTSD). A March 2008 rating decision denied service connection for PTSD as new and material evidence was not submitted. A September 2008 rating decision denied a service connection claim for depression. An August 2010 rating decision denied service connection for depression as new and material evidence was not submitted. A January 2014 rating decision denied a service connection claim for dysthymic disorder In July 2018, the Board reopened the service connection claim for a dysthymic disorder and remanded the claim for an addendum opinion to address the etiology of the Veteran’s dysthymic disorder. Turning to the evidence, a March 1980 report of medical examination indicates the Veteran reported she was treated for depression and nervous trouble by a family doctor before she began her military service. The examiner noted she had been seen by the mental health clinic in service. A March 1980 report of medical examination reported the Veteran’s psychiatric system was normal. A June 1985 reenlistment examination reported that the Veteran’s psychiatric system was normal. A July 1991 report of medical history documented the Veteran’s report that she experienced “nervous trouble of any sort.” The examining physician reported “nerves under control.” A June 1993 VA general medical examination report indicated that the Veteran “feels under stress.” The examiner reported that her stress was by history only and that no disease was found. VA treatment records compiled in November 2002 and November 2003 indicates that the Veteran reported no feelings of depression or hopelessness. An April 2004 VA primary care note indicates that the Veteran reported being under a lot of stress because her husband had colon cancer. She was diagnosed with anxiety/depression. A June 2004 VA primary care note documented the Veteran’s report of not being able to sleep and feeling anxious. She was prescribed Celexa for depression/anxiety A November 2004 VA primary care note reported the Veteran had a positive screen for depression but did not meet criteria for a diagnosis of major depressive disorder. A January 2005 VA psychiatry note reported the Veteran’s husband was very ill and she was having trouble sleeping and was amotivational. It was reported that she does not feel depressed at this point. A February 2005 VA psychiatry note reported that the Veteran recently lost her husband to cancer. She was diagnosed with bereavement with insomnia and anxiety. An April 2005 VA psychiatry note reported the Veteran had called the grief counselor from the hospice where her husband had died. She was diagnosed with depression. An April 2008 VA psychology note reported the Veteran was cheerful with generally euthymic mood, full-range, and appropriate affect. She denied any recent suicidal or homicidal ideation but noted she had experienced a period of major depression with suicidal ideation and hearing mood-congruent voices in 2006. She confirmed that she had largely recovered from a major depressive disorder episode but in recent weeks and months had still been troubled by regular periods of depressed mood lasting 1-2 days, with periods of normal mood up to many days in between. VA treatment records compiled in September 2010 and September 2011 report negative screenings for depression. The Veteran was provided a VA mental disorder examination in September 2013. The Veteran was diagnosed with dysthymic disorder under DSM-IV criteria. The examiner reported that symptoms encompassed by this diagnosis included depression for more days than not for over two years, anhedonia, irritability, anger, suicidal thoughts, crying spells, impaired concentration, feelings of hopelessness, feelings of helplessness, low energy, and low motivation. The examiner reported that the Veteran also struggled with anxiety. Anxiety symptoms were encompassed by the diagnosis of dysthymic disorder. During the Persian Gulf War, the Veteran was stationed in Saudi Arabia, 45 miles from the Kuwaiti border. She reported her duties included flying in a C-130 aircraft and transport teletyped information from one station to another station. She recalled seeing bodies in the desert that were swollen from the heat. She could not tell if the bodies were human or animals. She recalled that, when she first flew overseas, she was afraid her aircraft would be shot down. During her deployment, she reported that that were always on full alert and she was afraid she might not make it back to see my family. She also reported that the work hours were very long. The examiner opined that the Veteran’s psychiatric condition was at least as likely as not (50 percent probability or greater) caused by or the result of in-service military stressors. The Veteran was provided a VA mental disorders examination in June 2019. The examiner diagnosed with Veteran with unspecified anxiety disorder. He reported that her symptoms include feeling edgy and worrying, which had a minimal impact on functioning. The examiner reported that the symptoms stem from a history of depression due to traits of borderline personality disorder and remaining residuals of anxiety to prevent depressive symptoms from returning. The Veteran reported in 1993 or 1994, she was feeling depressed and having thoughts of death due to having lost multiple family members. The Veteran reported medication management was attempted but no medication worked. The Veteran reported she went back and forth to the VA for several years trying to find medications that worked. The Veteran reported that Wellbutrin has been an effective medication and she was happy with the results. The Veteran reported that she currently becomes depressed if situational stressors happen such as family illness, which will trigger her becoming depressed for several days until she balances herself and returns to normal functions. The Veteran reported being easily reactive to her environment and situations, which has been present her whole life. The Veteran reported she is learning to not react so quickly and irritably to her environment. The examiner opined that the Veteran’s unspecified anxiety disorder is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected condition. As rationale, the examiner explained that the Veteran is not diagnosed with a depressive disorder or any disorder due to any medical conditions. The examiner concluded that the September 2013 opinion appears to have been made in error, as the September 2013 examiner found that the death of her first husband in 2004 was a source of psychological distress for the Veteran and was unrelated to in-service military stressors. The examiner explained that a psychiatric consult four months prior to the September 2013 examiner’s evaluation diagnosed the Veteran with depression in partial remission and stated that her current symptoms of depression are in remission with the exception of occasional low mood. Therefore, the examiner found that the Veteran could not have had dysthymia in September of 2013, as dysthymia requires two complete years of depressive symptoms without remission. Therefore, the June 2019 examiner concluded that it appears the September 2013 examiner made an error not only in diagnosis but also whether it was related to in-service stressful conditions. The Veteran was provided another medical opinion in August 2020. After reviewing the Veteran’s claims file, the examiner opined that the Veteran’s acquired psychiatric disorder was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. As rationale, the examiner explained that the Veteran’s current diagnosis of unspecified anxiety disorder meets DSM-5 diagnostic criteria, but there is no evidence that it is related to her military service. The examiner explained that the Veteran’s service records show she was treated for anxiety prior to her military service and reportedly had a few visits for mental health conditions during her military service as noted on her separation examination, though the record did not specify if this was specifically related to anxiety. She has had some recurrent anxiety throughout her life since the military and has been treated for this, but her treatment for anxiety began prior to her military service. Therefore, there is no nexus between her military service and the current diagnosis of unspecified anxiety disorder. The examiner opined that the Veteran’s acquired psychiatric disorder was less likely than not (less than 50 percent probability) proximately due to or the result of Veteran’s service-connected migraine headaches. As rationale, the examiner explained that the Veteran has unspecified anxiety disorder that meets DSM-5 criteria. However, the disorder began prior to her service-connected migraine headaches and there is no documented connection between her migraine headaches and her anxiety in her claims file. The Veteran has a longstanding history of “spurts” of anxiety unrelated to migraine headaches, and in the current evaluation she also described occasional episodes of anxiety that relate to situational stressors, but she did not relate her anxiety to her headaches. Further, the evaluating psychologist stated her asthma and heart condition symptoms can sometimes mimic anxiety symptoms, but no other medical conditions were affecting the current mental disorder. The unspecified anxiety disorder is a separate entity entirely from the service-connected migraine headaches and unrelated to it. The examiner reported that she could not determine a baseline level of severity of the Veteran’s acquired psychiatric disorder based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by his service-connected migraine headaches. The examiner explained that the evidence does not show the Veteran’s anxiety was aggravated by her service-connected migraine headaches. Her March 1980 separation exam stated that she was treated for nervous trouble by her family doctor prior to joining the Army, but the baseline level of anxiety was not described. However, during the June 2019 VA mental disorders examination, the Veteran reported a lifelong history of anxiety/reactivity to her environment and stressful situations, which suggests her anxiety episodes have always been occasional, rather than chronic, and are triggered by a variety of psychosocial stressors. Regardless of an established baseline, the examiner opined that the Veteran’s acquired psychiatric disorder was less likely as not aggravated beyond its natural progression by her service-connected migraine headaches. As rationale, the examiner explained that the evidence throughout the Veteran’s medical record shows that her anxiety began prior to military service and tends to present as occasional episodes of anxiety, or “spurts” as she has described the episodes, which is consistent with her current description of anxiety episodes. Her current anxiety episodes are consistent with the lifelong “spurts” of anxiety she has described with no evidence of an aggravation of her anxiety beyond its natural progression by the service-connected migraine headaches. As previously described, a March 1980 report of medical examination reported the Veteran’s psychiatric system was normal. A July 1991 report of medical history documented the Veteran’s report that she experienced nervous trouble, but that the examining physician reported “nerves under control.” A June 1993 VA general medical examination report indicated that the Veteran “feels under stress.” The examiner reported that her stress was by history only and that no disease was found. VA treatment records compiled in November 2002 and November 2003 indicates that the Veteran reported no feelings of depression or hopelessness. An April 2004 VA primary care note indicates that the Veteran reported being under a lot of stress because her husband had colon cancer. She was diagnosed with anxiety/depression. While the Veteran believes she has an acquired psychiatric disorder that is related to an in-service injury, event, or disease, she is not competent to provide a nexus opinion in this case. The issue is medically complex and requires specialized knowledge and experience. Jandreau, 492 F.3d at 1377 n.4 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide an etiology opinion on this issue. Consequently, the Board gives more probative weight to the June 2019 VA examination and opinion and the August 2020 VA medical opinions. After reviewing the Veteran’s claims file and examining the Veteran, the June 2019 examiner concluded that the September 2013 opinion appears to have been made in error, as the September 2013 examiner found that the death of the Veteran’s first husband in 2004 was a source of psychological distress for the Veteran and was unrelated to in-service military stressors. The examiner explained that a psychiatric consult four months prior to the September 2013 examiner’s evaluation diagnosed the Veteran with depression in partial remission and stated that her current symptoms of depression are in remission with the exception of occasional low mood. Therefore, the examiner found that the Veteran could not have had dysthymia in September of 2013, as dysthymia requires two complete years of depressive symptoms without remission. Therefore, the June 2019 examiner concluded that it appears the September 2013 examiner made an error not only in diagnosis but also whether it was related to in-service stressful conditions. After reviewing the Veteran’s claims file, the August 2020 examiner opined that the Veteran’s acquired psychiatric disorder was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as there is no evidence that she has an acquired psychiatric disorder related to her military service. The examiner explained that the Veteran’s service records show she was treated for anxiety prior to her military service and reportedly had a few visits for mental health conditions during her military service as noted on her separation examination, though the record did not specify if this was specifically related to anxiety. She has had some recurrent anxiety throughout her life since the military and has been treated for this, but her treatment for anxiety began prior to her military service. The August 2020 examiner also opined that the Veteran’s acquired psychiatric disorder was less likely as not aggravated beyond its natural progression by her service-connected migraine headaches, as her current anxiety episodes are consistent with the lifelong “spurts” of anxiety she has described with no evidence of an aggravation of her anxiety beyond its natural progression by the service-connected migraine headaches. Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the appellant’s claim of service connection for an acquired psychiatric disorder. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service connection has not been established and the claim must be denied. 3. Entitlement to service connection for obstructive sleep apnea (OSA) is denied. The Veteran contends that she has OSA that is related to an in-service, event, illness, or injury, as she reported that her condition began after her overseas deployment. A January 2014 rating decision denied a service connection claim for OSA. In July 2018, the Board remanded the service connection claim for OSA for a VA examination. A March 1980 report of medical history documented the Veteran’s report that she did not have frequent trouble sleeping. A July 1991 report of medical history documented the Veteran’s report that she experienced frequent trouble sleeping. A June 1993 VA general medical examination reported the Veteran felt that she was under stress but did not report any problems with sleep. An August 2002 urgent care note reported the Veteran had no difficulty sleeping. A June 2004 VA primary care note documented the Veteran’s report of not being able to sleep and feeling anxious. A January 2005 VA psychiatry note reported the Veteran’s husband was very ill and she was having trouble sleeping. A February 2012 VA treatment note reported the Veteran was having difficulty staying asleep. The Veteran was provided a VA-contracted VA examination for her OSA in June 2019. The Veteran reported she developed problems with sleep after deployment overseas. She was diagnosed with obstructive sleep apnea in 2012 and has been using a CPAP machine ever since. A 2012 sleep study apnea-hypopnea index of 11.0, which is consistent with OSA. The examiner opined that the Veteran’s OSA was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. As rationale, the examiner explained that a diagnosis of OSA was not established until 2012, which was 20 years after separation from active service. During active service and the years following, there is no mention of sleep disturbance or any other airway condition which could be construed as a precursor to OSA. Therefore, direct service connection for this condition cannot be established based on available evidence in the Veteran’ claims file. As previously described, a July 1991 report of medical history documented the Veteran’s report that she experienced frequent trouble sleeping. However, a June 1993 VA general medical examination, conducted less than a year after the Veteran was discharged from active service in September 1992, reported the Veteran felt that she was under stress but did not report any problems with sleep. While the Veteran believes she has OSA that is related to an in-service injury, event, or disease, she is not competent to provide a nexus opinion in this case. The issue is medically complex and requires specialized knowledge and experience. Jandreau, 492 F.3d at 1377 n.4 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide an etiology opinion on this issue. Consequently, the Board gives more probative weight to the June 2019 VA examination report and opinion. After reviewing the Veteran’s claims file, the examiner opined that the Veteran’s OSA was less likely than not incurred in or caused by an in-service injury, event, or illness. As rationale, the examiner explained that OSA was not diagnosed until 20 years after service and there was no mention of sleep disturbance or any other airway condition that could be construed as a precursor to OSA during the Veteran’s active service and the years following. Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the appellant’s claim of service connection for OSA. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service connection has not been established and the claim must be denied. 4. Entitlement to service connection for degenerative joint disease (claimed as degenerative bone disease) is denied. The Veteran contends that she has degenerative joint disease that is related to an in-service, event, illness, or injury, as she reported that experienced body aches and pains after returning from her deployment to Southwest Asia. The Veteran filed a service connection claim for degenerative bone disease in October 2012, which was denied by the RO in a January 2014 rating decision. In July 2018, the Board remanded the service connection claim for degenerative bone disease for a VA opinion to address whether the Veteran’s arthritis documented in her VA treatment records is caused by or related to her in-service complaints of body aches and arm pain. Moreover, the July 2018 Board decision found that no new and material evidence had been submitted regarding the Veteran’s claim for service connection for a neck condition since the last final denial in August 2010. Thus, the remanded service connection claim for degenerative bone disease does not include the Veteran’ neck disorder. Turning to the evidence, a July 1991 report of medical history documented the Veteran’s report that she did not have swollen or painful joints or “bone, joint or other deformity.” A June 1993 VA general medical examination report did not document any complaints of joint pain or arthritis other than the Veteran’s back. In October 2020, the Veteran was provided a VA examination of his temporomandibular joint. The examiner reported that the Veteran does not now or ever had a temporomandibular joint condition. The Veteran denied a diagnosis of TMJ. The examiner opined that degenerative arthritis of the TMJ was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as no chronic diagnosis was made for degenerative arthritis of TMJ. In October 2020, the Veteran was provided a VA ankle conditions examination. The examiner reported that, although the Veteran does have some pain with dorsiflexion and plantar flexion of both feet, she does not have a diagnosis of a bilateral ankle condition in claims file and subjective symptoms today are not sufficient to render a diagnosis. The examiner reported that x-rays on the day of the examination were not clinically indicated. The examiner opined that degenerative arthritis of her ankles was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as no chronic diagnosis was made for degenerative arthritis of the Veteran’s ankles. The objective examination was normal. In October 2020, the Veteran was provided a VA elbow examination. The Veteran reported having bilateral elbow pain but did not know when it began. The examiner report that range or motion and strength in both elbows was normal. The examiner reported he was unable to find a diagnosis of an elbow condition in the Veteran’s claim file. The examiner reported that x-rays on the day of the examination were not clinically indicated. The examiner opined that degenerative arthritis of his elbows was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as no chronic diagnosis was made for degenerative arthritis of the Veteran’s elbows. The objective examination was normal. In October 2020, the Veteran was provided a VA foot conditions examination. The Veteran described very vague bilateral foot pain that began “some time ago.” To her knowledge she does not have a diagnosis of a foot condition. The examiner noted a 2004 diagnosis of bilateral pes cavus. The examiner reported that x-rays on the day of the examination were not clinically indicated. The examiner opined that degenerative arthritis of the Veteran’s feet was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as no chronic diagnosis was made for degenerative arthritis of the Veteran’s feet. In October 2020, the Veteran was provided a VA hand examination. The Veteran reported that she had bilateral hand pain that began several years ago but is unsure when it started. She denied any certain inciting event. The examiner reported that he was unable to find a current or chronic diagnosis of degenerative arthritis in the Veteran’s claims file. No diagnosis was rendered. The examiner reported that x-rays on the day of the examination were not clinically indicated. The examiner opined that degenerative arthritis of the Veteran’s hands was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as no chronic diagnosis was made for degenerative arthritis of the Veteran’s hands. The objective examination was normal. In October 2020, the Veteran was provided a VA hip examination. The Veteran reported that she experienced right hip after a hysterectomy in 2003. She reported that she saw a doctor at that time who seemed to think it was related to lower back pain and sciatica. She complained of right hip pain that comes and goes. The examiner reported that he was unable to find a current or chronic diagnosis of degenerative arthritis in the Veteran’s hips in the claims file. The examiner reported that x-rays on the day of the examination were not clinically indicated. No diagnosis was made on the day of the examination. The examiner opined that degenerative arthritis of the Veteran’s hips was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as no chronic diagnosis was made for degenerative arthritis of the Veteran’s hips. The objective examination was normal. In October 2020, the Veteran was provided a VA knee examination. The Veteran reported that her right knee had been hurting for some time, but she fell in 2017 and injured her right knee. She reported that no diagnosis was made after the fall. She reported that knee pain had been present for several years. The examiner reported she had mild knee pain. The examiner reported that x-rays on the day of the examination were not clinically indicated. No diagnosis was made on the day of the examination. The examiner opined that degenerative arthritis of the Veteran’s knees was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as no chronic diagnosis was made for degenerative arthritis of the Veteran’s knees. The objective examination was normal. In October 2020, the Veteran was provided a VA shoulder examination. The Veteran reported that she began experiencing bilateral shoulder pain in 2006. Since then her shoulder pain has reportedly waxed and waned. The examiner diagnosed the Veteran with bilateral shoulder strain. The examiner reported that x-rays on the day of the examination were not clinically indicated. The examiner opined that degenerative arthritis of the Veteran’s shoulders was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as no chronic diagnosis was made for degenerative arthritis of the Veteran’s shoulders. In October 2020, the Veteran was provided a VA wrist examination. The Veteran reported that she has had mild right wrist pain for several years off and on. She denied an injury event. The examiner reported that x-rays on the day of the examination were not clinically indicated. No diagnosis was made on the day of the examination. The examiner opined that degenerative arthritis of the Veteran’s wrists was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness, as no chronic diagnosis was made for degenerative arthritis of the Veteran’s wrists. The objective examination was normal. As previously described, a July 1991 report of medical history documented the Veteran’s report that she did not have swollen or painful joints or “bone, joint or other deformity.” A June 1993 VA general medical examination report, conducted less than a year after the Veteran was discharged from active service in September 1992, did not document any complaints of joint pain or arthritis other than the Veteran’s back. While the Veteran believes she has degenerative bone disease that is related to an in-service injury, event, or disease, she is not competent to provide a nexus opinion in this case. The issue is medically complex and requires specialized knowledge and experience. Jandreau, 492 F.3d at 1377 n.4 (Fed. Cir. 2007). Therefore, the Veteran is not competent to provide an etiology opinion on this issue. Consequently, the Board gives more probative weight to the October 2020 VA examination reports and opinions. After reviewing the Veteran’s claims file, the examiner opined that it was less likely than not that the Veteran has degenerative arthritis of the temporomandibular joint, ankles, elbows, feet, hands, hips, knees, shoulders, or wrists that were incurred in or caused by an in-service injury, event or illness. The examiner explained that the Veteran did not have degenerative arthritis of the temporomandibular joint, ankles, elbows, feet, hands, hips, knees, shoulders, or wrists Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran’s claim of service connection for degenerative joint disease. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service connection has not been established and the claim must be denied. REASONS FOR REMAND 1. Entitlement to service connection for a lumbar spine disorder is remanded. While further delay is regrettable, the Board finds that further development is required prior to adjudicating the Veteran’s claim for service connection for degenerative joint disease of the cervical spine. In July 2018, the Board reopened the Veteran’s service connection claim for a lumbar spine disorder. The Board found that the February 2015 VA examination was inadequate. Therefore, the Board remanded the claim for an addendum opinion and directed that the opinion should include September 2006 and June 2007 MRI findings in the analysis. The record shows that the Veteran first experienced back problems during her first period of active service. A January 7, 1980 service treatment record reported that the Veteran complained of back pain at the upper and lumbar region after doing physical training three days ago. It was reported that she had some loss of range of motion due to pain and was diagnosed with lower back pain. A January 23, 1980 service treatment record reported that the Veteran was experiencing backache, which was described as mild L-5 tenderness. A January 25, 1980 service treatment record reported that the Veteran was experiencing slight tightness of paraspinus muscles and was diagnosed with musculoskeletal pain. A March 1980 separation report of medical history documented the Veteran’s report that she had swollen or painful joints and “bones, joint or other deformity.” The physician’s notes reported that the Veteran states that she thinks her back is deformed because it hurts. She reported being treated by a private physician five years ago. The examiner reported no diagnosis of deformity. After the claim was remanded to the RO, the Veteran was provided an examination and medical opinion in June 2019. The Veteran was diagnosed with lumbosacral strain, degenerative arthritis of the spine and intervertebral disc syndrome. The examiner opined that the Veteran’s lumbar spine disorder was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. The examiner’s rationale stated that he found only “one entry in the pertinent files that mentions low back pain, dated 1/7/80, it is a [patient] consult note . . ..” The Veteran’s claims file includes the January 7, 1980 record referenced by the examiner, in which the Veteran complained of back pain as a result of physical training. However, the record also includes records from January 23, 1980 and January 15, 1980 reporting continued back pain. There is also a March 1980 separation report of medical history documenting the Veteran’s report of continued back pain. Because the examiner’s opinion was at least based in part on his conclusion that there was only one entry mentioning back pain in 1980 during the Veteran’s initial period of service, the Board finds the examiner’s opinion is inadequate, as a medical opinion based upon an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Due to the deficiencies of the June 2019 medical opinion, the Board finds that a remand is warranted for an addendum opinion to consider the complete history of the Veteran’s lumbar spine disorder to determine whether service connection is warranted. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stegall v. West, 11 Vet. App. 268 (1998). By this remand, the Board makes no determination, express or implied, concerning the credibility of any lay statements on file. 2. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. The July 2018 Board decision remanded the Veteran’s claim for TDIU as being inextricably intertwined with the Veteran’s service connection claims that were also remanded by the July 2018 Board decision. Once again, the TDIU claim is remanded as intertwined with the Veteran’s claim for entitlement to service connection to a lumbar spine disorder that is also being remanded herein. As such, the claim for a TDIU must be readjudicated on remand following the adjudication of the other claim remanded by the Board. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain all outstanding relevant private treatment records. 3. Return the claims file, including a copy of this remand, to the VA examiner who conducted the June 2019 VA back examination, or to another appropriate medical professional if that individual is unavailable, to provide an addendum opinion regarding the etiology of the Veteran’s acquired lumbar spine disorder. The Veteran’s claims file, to include a copy of this remand, must be made available to the examiner along with any other information the medical professional deems pertinent. If an additional examination is required for the examiner to sufficiently provide an etiology opinion, a new examination should be afforded. After a review of the claims file, the examiner should provide an opinion that answers the following question: Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s lumbar spine disorder is etiologically related to the Veteran’s active service? The opinion must reflect consideration of the medical and lay evidence of record. The examiner should set forth a complete rationale for all findings and conclusions and include the September 2006 and June 2007 MRI findings in the analysis. 4. After the development described above, and any additionally indicated development, has been completed, readjudicate the issues on appeal, including the inextricably intertwined issue of TDIU. If any determination remains unfavorable to the Veteran, send the Veteran and her representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Moore, 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.