Citation Nr: 21024180 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 17-59 617 DATE: April 22, 2021 ORDER New and material evidence having been received, the petition to reopen the Veteran's claim for service connection for a cervical spine disability is granted. New and material evidence having been received, the petition to reopen the Veteran's claim for service connection for a lumbar spine disability is granted. New and material evidence having been received, the petition to reopen the Veteran's claim for service connection for a respiratory disability is granted. Entitlement to service connection for bilateral sensorineural hearing loss is granted. Entitlement to service connection for degenerative arthritis of the lumbar spine is granted. REMANDED Entitlement to service connection for tinnitus is remanded. Entitlement to service connection for an acquired psychiatric disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. Entitlement to service connection for a bilateral shoulder disability is remanded. Entitlement to service connection for a heart disability, to include ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for pancreatitis is remanded. Entitlement to service connection for a respiratory disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. A January 1994 rating decision denied the Veteran’s claims of entitlement to service connection for a cervical spine disability, a lumbar spine disability, and a respiratory disability; the Veteran was notified of the decision in February 1994. A notice of disagreement was not filed, and additional evidence was not received within one year of the decision. 2. Evidence received since the January 1994 rating decision relating to the Veteran’s cervical spine disability, lumbar spine disability, and respiratory disability claims is neither cumulative nor redundant of the evidence of record at the time of the last final denial and relates to an unestablished fact necessary to substantiate the claims of service connection for a cervical spine disability, a lumbar spine disability, and a respiratory disability. 3. The Veteran has a diagnosis of bilateral sensorineural hearing loss. 4. The evidence is at least in equipoise as to whether the Veteran has demonstrated a continuity of symptomatology of bilateral sensorineural hearing loss since the end of his period of active service. 5. The Veteran has a diagnosis of degenerative arthritis of the lumbar spine. 6. The evidence is at least in equipoise as to whether the Veteran has demonstrated a continuity of symptomatology of degenerative arthritis of the lumbar spine since the end of his period of active service. CONCLUSIONS OF LAW 1. The January 1994 rating decision that denied claims for a cervical spine disability, a lumbar spine disability, and a respiratory disability became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence has been received to reopen the Veteran's claims of service connection for a cervical spine disability, a lumbar spine disability, and a respiratory disability. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.156, 20.1103. 3. The criteria for entitlement to service connection for bilateral sensorineural hearing loss have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.385. 4. The criteria for entitlement to service connection for degenerative arthritis of the lumbar spine have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the Air Force from January 1965 to January 1969. These matters come before the Board of Veterans’ Appeals (Board) on appeal of a September 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) that, in pertinent part, denied the Veteran’s petition to reopen previously denied claims for service connection for a cervical spine disability, a lumbar spine disability, and a respiratory disability; and denied new claims for service connection for bilateral hearing loss, tinnitus, a bilateral shoulder disability, a bilateral knee disability pancreatitis, an acquired psychiatric disability (claimed as posttraumatic stress disorder with alcohol use dependence), a heart disability (claimed as ischemic heart disease and/or residuals of stroke), hypertension (claimed as high blood pressure), and TDIU. The Veteran timely filed a notice of disagreement (NOD) in October 2015, identifying the appealed claims as relating to his cervical spine, lumbar spine, bilateral knees, acquired psychiatric disability, “ischemic heart disease/stroke,” TDIU, hearing loss, tinnitus, bilateral shoulder disability, hypertension, pancreatitis, and respiratory disability claims. A June 2017 statement of the case (SOC) reflects that the RO then considered the Veteran’s petition to reopen his respiratory disability claim to be reopened, though the claim remained denied on the merits; the rest of the claims identified in the October 2015 NOD remained denied as well. The Veteran timely perfected his appeal by Form 9 in November 2017. New & Material Evidence Generally, when a claim is disallowed, it may not be reopened and allowed unless new and material evidence is submitted. 38 U.S.C. § 5108. “New” evidence means existing evidence not previously submitted to agency decision-makers. “Material” evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The requirement of new and material evidence raising a reasonable possibility of substantiating the claim is a low threshold, to be viewed as “enabling rather than precluding reopening.” Shade v. Shinseki, 24 Vet. App. 110, 121 (2010). In adjudicating a claim for benefits, VA must consider all pertinent lay and medical evidence of record. 38 U.S.C. §§ 1154(a), § 5107; 38 C.F.R. § 3.303. For the purpose of reopening a claim, evidence received is generally presumed credible. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The June 2017 SOC reflects that the RO considers the Veteran’s respiratory disability claim reopened. However, regardless of the RO’s findings with regards to new and material evidence, the Board must determine de novo whether new and material evidence has been received. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). The Board must preliminarily decide whether new and material evidence has been presented in a case, before addressing the merits of the claim. Butler v. Brown, 9 Vet. App. 167, 171 (1996). 1. New and material evidence having been received, the petitions to reopen the Veteran's claims for service connection for a cervical spine disability, a lumbar spine disability, and a respiratory disability are granted. A January 1994 rating decision denied the Veteran’s claim of service connection for a cervical spine disability, then characterized as “neck strain”; a lumbar spine disability, then characterized as “back condition”; and a respiratory disability then characterized as “lung condition.” With respect to the cervical spine and lumbar spine claims, the February 1994 rating decision reflects discussion of in-service treatment in October 1966 following a motor vehicle accident. The RO made a finding that there was no evidence of a current cervical spine disability. As to the lumbar spine claim, the February 1994 rating decision discussed April 1968 in-service treatment for a strained back, evidence concerning post-service complaints of back pain leading up to a March 1987 back injury while carrying a piece of glass overhead, and noted that the Veteran has a “significant low back disability” and was status post L4-5 diskectomy. However, the in-service treatment was deemed to be for an acute and transitory condition that resolved without residual prior to separation. Since the February 1994 rating decision, VA has received the following evidence: private medical treatment records dated August 2015 reflecting complaints of neck pain and arm heaviness; December 2020 hearing testimony that the Veteran has experienced ongoing neck pain since the time of the October 1966 motor vehicle accident; a March 2010 VA examination reflecting moderate canal stenosis at L3-L4; and September 2012 private treating records reflecting a diagnosis of spinal stenosis. With respect to the respiratory disability claim, the February 1994 rating decision reflects discussion of in-service complaints of cough and tight chest, and May 1968 in-service treatment for pneumonia of the left lower lobe. The RO did not identify any current respiratory disability. Since the February 1994 rating decision, VA has received the following evidence: an April 2015 VA examination reflecting diagnoses of asthma and chronic obstructive pulmonary disease; and statements by the Veteran that he was exposed to hazardous materials while in service, to include herbicide agents either while in the Republic of Vietnam, in Thailand, and/or while working around C-130 aircraft, to which he attributes his current claimed respiratory disability. The Board finds that this medical and lay evidence is new as it had not been previously submitted to the RO, and material as it pertains to the bases for the prior final denials, that is that the Veteran had no current cervical spine disability or respiratory disability; and that there was no nexus between the Veteran’s active service and his claimed respiratory and lumbar spine disabilities. The Board thus concludes that new and material evidence has been received since the time of the February 1994 rating decision denying service connection for a cervical spine disability, a lumbar spine disability, and a respiratory disability. Accordingly, the petition to reopen the previously denied claims for service connection for a cervical spine disability, a lumbar spine disability, and a respiratory disability are granted. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. In adjudicating claims for VA benefits, the burden of proof only requires an “approximate balance” of the evidence for and against a claim. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1991). This low standard of proof is “unique” to the VA adjudicatory process, and “the nation, ‘in recognition of our debt to our veterans,’ has ‘taken upon itself the risk of error’ in awarding such benefits.” Wise v. Shinseki, 26 Vet. App. 517, 531 (2014). In evaluating a claim for disability benefits, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. 1. Entitlement to service connection for bilateral sensorineural hearing loss is granted. 38 C.F.R. § 3.385 provides that, for VA purposes, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz (Hz) is 40 decibels (dB) or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. Acoustic trauma due to loud noise has been accepted as satisfying the in-service disease or injury element of a claim for disability compensation. Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012), Hensley v. Brown, 5 Vet. App. 155, 159 (1993). At his December 2020 hearing the Veteran testified as to his exposure the noise of C-130 and F-4 aircraft that flew overhead, or landed near, the supply warehouse where he worked; the Veteran also described running equipment out to waiting C-130s. The Board finds this testimony consistent with the nature and circumstances of his service, and notes that the Veteran’s Form DD 214 reflects that he served as a Materials Facility Specialist, and that a January 1966 performance evaluation describing the Veteran’s service as a Supply Expediter – Night Shift Leader documents duties processing items “on a priority basis for delivery and issue to flight line activities in direct support of C-130 and F-4C aircraft.” The Board thus finds the in-service injury element of the Veteran’s hearing loss claim is satisfied consistent with Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012) and Hensley v. Brown, 5 Vet. App. 155, 159 (1993). An April 2015 VA examination report reflects right ear auditory threshold frequencies of 20, 20, 30, 55, and 70 dB at 500, 1000, 2000, 3000, and 4000 Hz, respectively, and a Maryland CNC Test speech discrimination score of 88 percent; and left ear auditory threshold frequencies of 20, 20, 35, 60, and 75 Hz, respectively, and a Maryland CNC Test speech discrimination score of 92 percent. The examiner diagnosed the Veteran with bilateral sensorineural hearing loss. The Board finds that the Veteran has a current hearing loss disability for VA purposes. The examiner opined that the Veteran’s bilateral sensorineural hearing loss was less likely than not the result of his active service. While the examiner acknowledged the Veteran’s report of noise exposure while in service, the examiner stated that the Veteran’s entrance and separation examinations did not reflect any significant worsening in his hearing during the course of his service. The examiner also noted a significant history of post-service noise exposure, to include work in a fabric factory and 14 years of high-rise construction. However, sensorineural hearing loss is an organic disease of the nervous system, a chronic disease under 38 C.F.R. § 3.309(a) for which service connection may be granted solely based on continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). At his December 2020 hearing, the Veteran testified that his hearing loss symptoms pre-dated his post-service work in high-noise environments and that he began noticing hearing loss symptoms soon after his period of active service. Accordingly, the Board concludes that the criteria for entitlement to service connection for bilateral hearing loss have been met, and the same is hereby granted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.385. 2. Entitlement to service connection for degenerative arthritis of the lumbar spine is granted. Private medical treatment records dated April 1987 reflect a diagnosis of degenerative facet arthritis at L5-S1. There is no evidence to suggest that this diagnosis has resolved. Thus, the Board finds that the evidence is at least in equipoise as to whether the Veteran has a current diagnosis of degenerative arthritis of the lumbar spine. Resolving the benefit of the doubt in the Veteran’s favor, the Board concludes that the current diagnosis element of the criteria for service connection has been satisfied. Arthritis is among those disabilities for which VA may presume a nexus between an in-service incurrence or event and a current disability provided there is a showing of continuity of symptomatology. 38 C.F.R. §§ 3.303(b), 3.309(a). The Veteran’s service treatment records (STRs) reflect that he was in a motor vehicle accident in October 1966, at which time he complained of back pain. An April 1968 in-service treatment note reflects complaints that the Veteran “strained” his back while working on a forklift. The April 1987 private medical treatment note reflects a diagnosis of degenerative facet arthritis at L5-S1. The Veteran reported to an October 2010 VA examiner that his “back condition was long-standing.” In January 2015 a private treating provider described the Veteran as being in “significant back pain.” At his December 2020 hearing the Veteran testified that he began receiving treatment for low back pain since at least 1971. The evidence is at least in equipoise as to whether the Veteran has demonstrated continuity of symptomatology of his degenerative arthritis of the lumbar spine. As noted above, service connection for degenerative arthritis may be awarded based solely on continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013). Accordingly, the Board concludes that the criteria for entitlement to service connection for degenerative arthritis of the lumbar spine have been met, and the same is hereby granted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.309. REASONS FOR REMAND VA will provide a medical examination or obtain a medical opinion where there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with a veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 82-83 (2006) 1. Entitlement to service connection for tinnitus is remanded. As discussed above, the Veteran is now service connected for bilateral sensorineural hearing loss. The April 2015 VA examiner who performed the audiological evaluation discussed above did not opine as to the cause of the Veteran’s claimed tinnitus, providing only a negative opinion that it was less likely than not the result of military noise exposure. However, service connection may also be established on a secondary basis. To establish secondary service connection, a Veteran must provide evidence of (1) a current, non-service-connected disability, (2) a current service-connected disability, and (3) evidence that the non-service-connected disability is either (i) proximately due to or the result of a service-connected disability or (ii) aggravated (increased in severity) beyond its natural progression by a service-connected disability. 38 U.S.C. § 1110; Allen v. Brown, 7 Vet. App. 439, 446 (1995); 38 C.F.R. § 3.310. The Veteran’s claim should be remanded to obtain a VA medical opinion as to whether his tinnitus is at least as likely as not proximately due to, the result of, or aggravated by his service connected bilateral sensorineural hearing loss. 2. Entitlement to service connection for a cervical spine disability; a bilateral knee disability; and a bilateral shoulder disability are remanded. Private medical treatment records dated in August 2015 reflecting complaints of neck pain and arm heaviness and in December 2020 the Veteran testified that he has experienced ongoing neck pain since the time of the October 1966 motor vehicle accident. At his December 2020 hearing the Veteran also testified that he had been experiencing bilateral knee pain since at least 1971, and contended that this pain was the result of repeatedly running equipment out to C-130 aircraft. In light of the foregoing, the Board finds that the Veteran’s cervical spine; bilateral knee; and bilateral shoulder disability claims should be remanded to obtain VA examinations and medical opinions as to the nature and cause of any cervical spine; bilateral knee; and bilateral shoulder disabilities, to include as secondary to his service connected lumbar spine disability. 3. Entitlement to service connection for an acquired psychiatric disability is remanded. The Veteran contends that he suffers from posttraumatic stress disorder (PTSD), which he attributes to events in service. The Board notes that while the Veteran has characterized his claim as one for PTSD specifically, VA should construe a claim based on the reasonable expectations of the non-expert, self-represented claimant and the evidence developed in processing that claim. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (U.S. 2009). Accordingly, the Board construes the Veteran’s instant claim as one for an acquired psychiatric disability, to include PTSD. The Veteran’s military personnel records reflect positive performance reviews in January 1966, November 1966, and November 1967. The Veteran then went absent without leave (AWOL) for a period of approximately 6 days in May 1968 and was then subject to Article 15 proceedings. An August 1968 selective reenlistment screening form described the Veteran as having disciplinary problems and that his “attitude toward military life is not good.” Mental health treatment records from 2015 and 1988 have been associated with the claims file, however, neither reflect clear diagnoses of any acquired psychiatric disability. The Veteran has submitted two evaluations by a private provider dated December 2017 and December 2015. In the December 2017 evaluation the provider stated that “it is possible [the Veteran] had experienced symptoms characteristic of having a diagnosis of PTSD” and that the Veteran did “appear to be experiencing a high degree of depression.” The Board finds that, while probative, these statements do not rise to the level of “at least as likely as not.” The Veteran attributes his claimed acquired psychiatric disability to multiple events in service, to include seeing a fellow service member beaten at Udorn Royal Thai Air Force Base; being involved in a fight with fellow service members at Naha Air Base; handling body bags at Da Nang in the Republic of Vietnam; and being ordered to use force against protestors while stationed in England. The Veteran also testified as to his history of mental health treatment. September 2016 correspondence associated with the claims file reflects that the RO attempted to verify the Veteran’s report of seeing a fellow service member beaten at Udorn Royal Thai Air Force Base. However, the response from the Department of the Air Force reflects that the only investigative measures taken were to use the Veteran’s identifying information on a search in various databases, rather than any information related to the individual the Veteran reports having seen assaulted. The Veteran has provided VA with the name of that individual. Moreover, a DPRIS response which did reference the assault victim noted that if an investigation was conducted into this assault case by base Law Enforcement or base Security, then this information may be maintained by Headquarters, U.S. Air Force Office of Special Investigations (OSI), 27130 Telegraph Road, Quantico Virginia. No follow-up appears to have been conducted. Moreover, the record does not reflect any other attempts by the RO to verify any of the other events to which the Veteran attributes his claimed acquired psychiatric disability. In light of the foregoing, the Board finds that the Veteran’s acquired psychiatric disability claim should be remanded for the RO to take appropriate steps to attempt to verify the Veteran’s reports of events in service, and for the Veteran to be afforded an appropriate VA examination to determine the nature and cause of any acquired psychiatric disabilities. 4. Entitlement to service connection for a heart disability, to include ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke; hypertension; pancreatitis; and a respiratory disability are remanded. The Veteran has filed claims of service connection for a heart disability, variously characterized as ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke; hypertension; pancreatitis; and a respiratory disability, variously characterized as asthma, emphysema, and/or chronic obstructive pulmonary disorder, (COPD). The Veteran contends that these disabilities are the result of exposure to various hazardous materials while in service, to include herbicide agents, aircraft antifreeze, forklift hydraulic fluid, and/or airplane fuel. As discussed above, the Veteran has reported being present in both the Republic of Vietnam and a Royal Thai Air Force Base. The record does not reflect any attempts by the RO to verify the Veteran’s claimed exposure to hazardous materials while in service, to include herbicide agents, aircraft antifreeze, forklift hydraulic fluid, and/or airplane fuel. An April 2015 VA examiner documented a diagnosis of pancreatitis. The same examiner documented diagnoses of asthma and COPD, though the date assigned to these diagnoses is vague (“2000s”), and it is thus unclear whether the examiner is reporting an independent finding concerning respiratory disability diagnoses, or documenting the Veteran’s report. A March 2013 private treatment record reflects a hospital admission for a transient ischemic attack, as well as a diagnosis of hypertension. In light of the foregoing, the Veteran’s heart disability, to include ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke; hypertension; pancreatitis; and respiratory disability claims should be remanded for the RO to take appropriate steps to attempt to verify the Veteran’s reports of exposure to hazardous materials, include herbicide agents, aircraft antifreeze, forklift hydraulic fluid, and/or airplane fuel, and for the Veteran to be afforded appropriate VA examinations to determine the nature and cause of his claimed disabilities. 5. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. Because evidence developed in the course of adjudicating the Veteran’s claim of service connection for tinnitus; a cervical spine disability; a bilateral knee disability; a bilateral shoulder disability; an acquired psychiatric disability; a heart disability, to include ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke; hypertension; pancreatitis; and a respiratory disability could significantly impact a decision on the issue of entitlement to TDIU, the issues are inextricably intertwined and a remand is required. The matters are REMANDED for the following action: 1. Take appropriate steps to verify both the Veteran’s claimed in-service stressors and his exposure to hazardous materials, to include herbicide agents, aircraft antifreeze, forklift hydraulic fluid, and/or airplane fuel. All requests for information should be documented and associated with the claims file. 2. After remand directive 1 has been completed, schedule the Veterans for examinations by appropriate clinicians to determine the nature and etiology of his claimed tinnitus; cervical spine disability; bilateral knee disability; bilateral shoulder disability; acquired psychiatric disability; heart disability, to include ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke; hypertension; pancreatitis; and respiratory disability. 3. With respect to the Veteran’s tinnitus, the examiner should identify and discuss any tinnitus diagnosis identified during the examination and/or during the pendency of this claim, and respond to the following questions: (a.) Whether the Veteran’s tinnitus is at least as likely as not related to an in-service injury, event, or disease, or whether it first had its onset during a period of active service. (b.) Whether the Veteran’s tinnitus is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability. If aggravation is found, the examiner should attempt to identify the baseline level of disability prior to such aggravation 4. With respect to the Veteran’s claimed acquired psychiatric disability, the examiner should identify and discuss any acquired psychiatric disabilities, to include PTSD, identified during the examination and/or during the pendency of this claim, and respond to the following questions: (a.) Whether any identified acquired psychiatric disability is at least as likely as not related to an in-service injury, event, or disease, or whether it first had its onset during a period of active service. (b.) Whether any identified acquired psychiatric disability is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability. If aggravation is found, the examiner should attempt to identify the baseline level of disability prior to such aggravation The examiner should identify with specificity the source of information regarding any documented acquired psychiatric disability diagnoses. 5. With respect to the Veteran’s claimed cervical spine, bilateral knee, and bilateral shoulder disabilities, the examiner should identify and discuss any cervical spine, bilateral knee, and bilateral shoulder disabilities identified during the examination and/or during the pendency of this claim, and respond to the following questions: (a.) Whether any identified cervical spine, bilateral knee, and bilateral shoulder disabilities are at least as likely as not related to an in-service injury, event, or disease, or whether it first had its onset during a period of active service. (b.) Whether any identified cervical spine, bilateral knee, and bilateral shoulder disabilities are at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond their natural progression by service-connected disability. If aggravation is found, the examiner should attempt to identify the baseline level of disability prior to such aggravation The examiner should identify with specificity the source of information regarding any documented cervical spine, bilateral knee, and bilateral shoulder diagnoses. 6. With respect to the Veteran’s claimed heart disability, to include ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke; hypertension; pancreatitis; and respiratory disability, the examiner should identify and discuss any such disabilities identified during the examination and/or during the pendency of this claim and respond to the following questions: (a.) Whether any identified claimed heart disability, to include ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke; hypertension; pancreatitis; and respiratory disability is at least as likely as not related to an in-service injury, event, or disease, or whether it first had its onset during a period of active service. (b.) Whether any identified claimed heart disability, to include ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke; hypertension; pancreatitis; and respiratory disability is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond their natural progression by service-connected disability. If aggravation is found, the examiner should attempt to identify the baseline level of disability prior to such aggravation The examiner should identify with specificity the source of information regarding any documented heart disability, to include ischemic heart disease, arteriosclerotic heart disease, and/or residuals of stroke; hypertension; pancreatitis; and respiratory disability diagnoses. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. C. Sametshaw 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.