Citation Nr: 21028396 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-12 604 DATE: May 11, 2021 ORDER Entitlement to service connection for insomnia is denied. Entitlement to service connection for residuals of removal of gall bladder is denied. Entitlement to service connection for chronic inflammatory disease is denied. Entitlement to service connection for pruritis is denied. REMANDED Entitlement to service connection for right carpal tunnel syndrome is remanded. Entitlement to service connection for a disability manifested by chest pain is remanded. Entitlement to service connection for a skin disability, claimed as dermatitis and skin tags, to include as secondary to service-connected diabetes mellitus is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. Entitlement to service connection for residuals of rhinoplasty, to include deviated nasal septum, is remanded. Entitlement to service connection for a disability manifested by dyspnea is remanded. Entitlement to service connection for gout is remanded. Entitlement to service connection for a cervical spine disability, claimed as neck pain and cervicalgia, is remanded. Entitlement to service connection for a right knee disability is remanded. FINDINGS OF FACT 1. The preponderance of the competent, credible, and probative evidence weighs against a finding that the Veteran has a current disability manifested by insomnia that is separate and distinct from his service-connected depressive disorder. 2. The preponderance of the competent, credible, and probative evidence weighs against a finding that the Veteran has manifested residuals of gallbladder removal at any point during or in close proximity to the appeal period, to include as secondary to his service-connected diabetes mellitus. 3. At no time prior to the filing of the claim or during the pendency of the claim, does the competent lay or medical evidence show the Veteran has manifested chronic inflammatory disease. 4. The preponderance of the competent, credible, and probative evidence weighs against a finding that the Veteran's pruritis is separate and distinct from his service-connected eczema disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for insomnia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for residuals of removal of gall bladder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for entitlement to service connection for chronic inflammatory disease have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for pruritis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1970 to April 1990. This appeal was previously before the Board in December 2018, at which time the Board remanded the claims on appeal for evidentiary development. All requested development has been conducted with respect to the claims decided herein; however, for reasons explained below, additional evidentiary development is needed for the claims discussed in the remand section of this decision. 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. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (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. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for insomnia In May 2012, the Veteran filed a claim seeking service connection for several disabilities, including insomnia, which he asserted was secondary to service-connected hypertension, allergic rhinitis, and sinusitis. In a statement submitted in October 2019, the Veteran stated that he has struggled with insomnia and other symptoms since being diagnosed with bronchitis in 1977 and that he believed those symptoms contributed to his sleep apnea. In this regard, the Board notes that, in November 2014, the Veteran's private physician, Dr. Modesto, stated that the Veteran has insomnia due to obstructive sleep apnea. While Dr. Modesto's statement is considered competent medical evidence, the probative value of the statement is significantly lessened because he did not provide a rationale in support of his conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion, not the mere fact that the claims file was reviewed). The Board also finds that Dr. Modesto's statement and conclusion is outweighed by the preponderance of the other evidence of record which reflects that the Veteran's insomnia is a manifestation of the chronic sleep impairment that is attributed to his service-connected depressive disorder. The evidence reflects that the Veteran is currently in receipt of a 50 percent disability rating for service-connected depressive disorder which is manifested by chronic sleep impairment and other moderately severe symptoms. See February 2016 Rating Decision; see also VA examinations dated October 2013 and December 2019. The December 2019 VA examiner specifically noted that the Veteran's insomnia and sleep disturbances are secondary to his depression and a representative symptom therein. See December 2019 VA mental disorders examination. The evidence of record does not document any complaints or treatment for insomnia separate from the Veteran's service-connected depressive disorder and the Veteran has not identified any outstanding medical evidence that would show he currently has a disability manifested by insomnia that results in a functional impairment that is separate and distinct from the chronic sleep impairment attributed to his service-connected depressive disorder. As noted, the medical evidence of record that suggests the Veteran's insomnia is due to obstructive sleep apnea has no probative value because it is not supported by a rationale. Therefore, as the preponderance of the lay and medical evidence does not show that the Veteran currently has a disability manifested by insomnia that is separate and distinct from his service-connected depressive disorder, service connection for insomnia must be denied. 2. Entitlement to service connection for residuals of removal of gall bladder The evidence reflects that, in July 2009, the Veteran sought treatment for severe epigastric pain that he reported had a sudden onset after eating that day with a similar episode one year earlier that resolved spontaneously. A right upper quadrant ultrasound revealed acute cholecystitis with cholelithiasis, after which a cholecystectomy was performed. See private treatment records dated July 2009. In May 2012, the Veteran filed a claim seeking service connection for several disabilities, including residuals of gallbladder removal which he asserted is secondary to service-connected diabetes mellitus. During the December 2019 VA examination, the Veteran reported that, since 2009, he has had acid reflux with bloating and alternating constipation and diarrhea which have been treated with medication. After examining the Veteran, the December 2019 VA examiner stated there were no findings, signs, or symptoms to support a diagnosis of residuals of gallbladder removal. As for the clinical symptoms reported by the Veteran, the examiner stated the Veteran's symptoms of diarrhea and constipation are nonspecific and do not necessarily point to any specific diagnosis, whereas the other symptoms are consistent with a probable diagnosis of gastroesophageal reflux disease (GERD), none of which are complications or residuals of a cholecystectomy. See December 2019 VA gallbladder examination. The VA examiner also stated that there is no medical literature to support a causal connection between diabetes and cholecystitis or any other gallbladder condition. See December 2019 VA opinion. In evaluating this claim, the Board places great probative weight on the opinion provided by the December 2019 VA examiner, as the opinion has a clear conclusion and supporting data, as well as a reasoned medical explanation connecting the two based that is based upon review of the claims file, examination of the Veteran, and medical expertise. The December 2019 opinion is also consistent with the conclusion provided by the October 2013 examiner that the Veteran does not have a chronic gallbladder condition. Notably, there is no other medical evidence or opinion of record that states the Veteran has any residual symptoms or conditions of the gallbladder removal, to include any symptoms that are due his service-connected diabetes mellitus. The only evidence of record that suggests the Veteran has a residual condition from removal of his gallbladder or that any residuals of the cholecystectomy are the Veteran's own statements, but the Veteran's assertions in this regard are not considered persuasive. Indeed, opinions regarding the etiology of conditions involving the biliary system, including the gallbladder, are complex and generally beyond the competency of a lay witness. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The evidence does not reflect, nor has the Veteran alleged, that he has any medical education, experience, or training; nor has he offered any basis in common lay knowledge to support his assertions attributing his residual symptoms, including those attributed to a diagnosis of GERD, to either the gallbladder removal performed in 2009 or his service-connected diabetes mellitus disability. Instead, the Veteran's statements and beliefs regarding the cause of his reported residual symptoms are based upon own assertions that are not supported by any medical evidence or basis in common lay knowledge. As noted, medical professionals have examined the Veteran, reviewed the evidence, and opined that the Veteran does not have any residuals of gallbladder removal, to include his reported symptoms of diarrhea, constipation, and GERD. Therefore, the Veteran's statements are not considered more persuasive than the medical opinions of record. Accordingly, the Board finds the preponderance of the competent, credible, and probative evidence is against a finding that the Veteran has manifested residuals of gallbladder removal at any point during or in close proximity to the appeal period, to include as secondary to his service-connected diabetes mellitus. As such, the Veteran's claim is denied, and the benefit of the doubt doctrine is not applicable. 3. Entitlement to service connection for chronic inflammatory disease The Veteran has generally asserted that he has chronic inflammatory disease that is due to his exposure to contaminants in service. See Veteran statement. Despite his general assertion, the Veteran has not reported or described having any symptoms generally associated with a chronic inflammatory disease during or after his period of active service; nor has he submitted or identified any medical evidence that shows treatment for or diagnosis of chronic inflammatory disease. In this regard, the Board's review of the Veteran's service and post-service treatment records does not reveal any complaints or treatment for symptoms of or a diagnosis of chronic inflammatory disease. In fact, the December 2019 VA examiner noted the Veteran did not have a history of chronic inflammatory disease and that he was unable to provide a specific history for his claimed chronic inflammatory disease. Instead, when discussing this condition, the Veteran reported multiple other diagnoses such as diabetes mellitus, skin problems, shortness of breath, sinusitis, and fatigue. The examiner noted the Veteran's history of gout but stated the Veteran did not report any other diagnosis consistent with chronic inflammatory disease resulting from an autoimmune disorder, such as lupus. Indeed, after conducting arthritis and autoimmune diseases examinations, the VA physician noted there were no findings, signs, or symptoms to support a diagnosis of chronic inflammatory disease. See December 2019 VA autoimmune diseases and arthritis examination reports. In evaluating this claim, the Board finds probative that the Veteran has not provided any lay statements endorsing persistent or recurrent symptoms that are generally associated with a diagnosis of chronic inflammatory disease, such as chronic inflammation or pain affecting the entire body; nor has he submitted statements indicating that his claimed chronic inflammatory disease results in a functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356, 1367-69 (Fed. Cir. 2018) (pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability if it reaches the level of a functional impairment of earning capacity). Indeed, while the Veteran is competent to report having symptoms such as inflammation, pain, or fatigue, he has not provided any competent or credible lay or medical evidence of any such symptoms, including during outpatient treatment or when provided VA examinations in conjunction with this case. The requirement of a current disability is satisfied when the Veteran has a disability at the time he filed his service connection claim, during the pendency of that claim, or just prior to the filing of a claim, even if the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C. § 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Indeed, in the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Therefore, service connection for chronic inflammatory disease is not warranted, as the lay and medical evidence of record does not reflect that this condition was manifest during service or at any time during the pendency of the claim or just prior to the filing of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Accordingly, the Veteran's claim is denied. 4. Entitlement to service connection for pruritis The Veteran is seeking service connection for several skin disabilities, including dermatitis, skin tags, and pruritis, all of which he has claimed are due to his service-connected diabetes mellitus. See Veteran statements dated May 2012 and December 2013; various articles submitted in December 2019. The Board notes that service connection has been established for eczema, specifically including nodules on the head, face, and neck. See February 2016 Rating Decision. In this regard, the Board notes that, while the Veteran has sought service connection for pruritis, the preponderance of the evidence reflects that his pruritis is a manifestation of his service-connected eczema disability. Indeed, the December 2019 VA examiner stated that the Veteran's pruritis is not a separate condition or diagnosis but is, instead, a manifestation of eczema, and the Board notes that the VA examiner's opinion is supported by the other evidence of record. See December 2019 VA skin examination report. The STRs show the Veteran received treatment for various skin conditions during service, including eczema that was manifested by pruritis and a scaly, nummular patch of skin on his right knee and finger. See STRs dated October and November 1974. Post-service treatment records also document the Veteran's diagnosis of eczema, which is shown to be manifested by dry, pruritic skin all over his body, including his fingers. See August 2007 private treatment record. The Board acknowledges that, in December 2010, the Veteran reported having significantly pruritic skin on his legs and back, which was diagnosed as xerosis cutis; however, the Board finds probative that clinicians have variously identified the dry, itchy skin all over the Veteran's body as eczema and xerosis. See e.g., private treatment records dated October 2009 and December 2010; see also January 2019 VA treatment record. Notably, there is no medical evidence or opinion of record that shows or suggests that the Veteran's pruritis is a separate and distinct condition or disability from his service-connected eczema disability, and the Veteran's assertions in this regard are not considered persuasive. Indeed, opinions regarding the nature and etiology of skin disorders are complex and generally beyond the competency of a lay witness. See Jandreau, 492 F.3d at 1372. The evidence does not reflect, nor has the Veteran alleged, that he has any medical education, experience, or training; nor has he offered any basis in common lay knowledge to support his assertions that his pruritis represents a disability separate and distinct from his service-connected eczema disability. By contrast, medical professionals have reviewed the claims file, examined the Veteran, and opined that his pruritis is a manifestation of his service-connected eczema disability without any opposing lay or medical evidence that is deemed more probative. Therefore, the Board finds the preponderance of the competent, credible, and probative evidence establishes that the Veteran's pruritis is a manifestation of his service-connected eczema disability, as opposed to a separate and distinct disability for which service connection may be granted. As such, the Veteran's claim is denied, and the benefit of the doubt doctrine is not applicable. However, the Veteran is advised that he may wish to file an increased rating claim for his service-connected eczema disability, as the evidence shows his disability involves his extremities and back, as well as his head, face, and neck. REASONS FOR REMAND 1. Entitlement to service connection for right carpal tunnel syndrome The Veteran initially asserted that he believed his carpal tunnel syndrome was due to exposure to various contaminants during service; however, during the July 2013 VA examination, he reported that his job in the optical laboratory during service required repetitive wrist motion - the right wrist more than the left - and using both thumbs to push lenses into the frames. The evidence reflects that the Veteran also reported that twisting, turning, and otherwise using optical machines during service resulted in a right elbow disability, for which service connection has been granted. See August 2012 VA elbow examination. However, VA has not obtained a medical opinion that addresses whether the Veteran's right carpal tunnel syndrome disability was incurred as a result of the duties he performed during service or, in the alterative, is due to or aggravated by his service-connected right elbow disability. In this regard, it appears VA did not obtain a medical opinion because the Veteran's right carpal tunnel syndrome was deemed asymptomatic when initially diagnosed and during the July 2013 VA examination. See e.g., October 2008 private medical record from Coastal Neurology; July 2013 VA wrist examination. Nevertheless, the evidence reflects that the Veteran has endorsed having pain and right frozen fingers due to carpal tunnel syndrome during the appeal period, which suggests that his disability has been symptomatic during the appeal period. See December 2014 VA treatment record. Given the foregoing, the Board finds a VA opinion regarding the Veteran's right carpal tunnel syndrome must be obtained before a fully informed decision may be rendered. 2. Entitlement to service connection for a disability manifested by chest pain The Veteran is seeking service connection for chest pain that he has asserted is due to exposure to various contaminants during service, but he has also attributed his chest pain to a non-specific heart disability. See undated Veteran statement and September 2004 Veteran statement. In December 2018, the Board remanded this claim in order for a VA clinician to state whether any disability manifested by chest pain was found and to obtain a medical opinion that addressed whether any such disability is due to exposure to contaminants during service or secondary to (proximately due to or aggravated by) any of the Veteran's service-connected disabilities, to specifically include rhinitis, sinusitis, or hypertension. The Veteran was afforded a VA muscles examination in December 2019 during which he reported that he began having recurring episodes of chest pain in 2012 for which he was given a comprehensive evaluation that did not result in any specific diagnosis. He reported that his current symptoms included dull, right upper chest pain while breathing. After examining the Veteran, the VA examiner stated that there were no findings, signs, or symptoms to support a diagnosis of a disability manifested by chest pain. The examiner further noted that examination of the chest was normal and that the medical records did not reveal any findings to support any muscle diagnosis or pathology. See December 2019 VA muscles examination. Accordingly, the VA examiner stated that direct service connection could not be established as there was no diagnosis and that the claimed chest muscle condition was less likely than not incurred or caused by an in-service injury, event, or illness. See December 2019 VA opinion. While the VA examiner noted there were no findings, signs, or symptoms to support a diagnosis of a disability manifested by chest pain, to include a muscle condition, there remains a question of whether the Veteran's reported chest pain is manifestation or symptom of his service-connected hypertension or hypertensive cardiovascular disease or, in the alternative, causes functional loss or impairment that can be considered a separate and distinct disability that is proximately due to or aggravated by his service-connected hypertension or hypertensive cardiovascular disease. In this regard, the Board notes that the lay and medical evidence of record suggests that the Veteran's chest pain may be associated with or due to his hypertension or other heart disabilities. See e.g., treatment records dated November 2004 and VA treatment records dated January and March 2012. Therefore, a remand is needed to obtain an additional medical opinion. 3. Entitlement to service connection for a skin disability, including dermatitis and skin tags, to include as secondary to service-connected diabetes mellitus is remanded. As noted, the Veteran is seeking service connection for several skin disabilities, including dermatitis and skin tags, both of which he has claimed are due to his service-connected diabetes mellitus. See Veteran statements dated May 2012 and December 2013; various articles submitted in December 2019. The evidence shows that, since filing his claim in May 2012, the Veteran has sought treatment for various skin conditions that have been diagnosed as tinea, pilar cysts, and seborrheic dermatitis. See e.g., VA treatment records dated August 2014 and January 2019; see also November 2014 statement from Dr. Modesto. In December 2018, the Board remanded this claim in order for a VA clinician to diagnose any skin tags, dermatitis, or diabetes-related skin disability and to obtain a medical opinion that addressed whether any such disability had its onset during service, to include as due to exposure to contaminants, or is secondary to (proximately due to or aggravated by) any of the Veteran's service-connected disabilities, to specifically include diabetes or eczema. Following the December 2019 VA skin examination, the examiner stated there were no findings, signs, or symptoms to support a diagnosis of a diabetes-related skin condition, skin tags, or contact dermatitis and further noted that the diagnosis of pilar cysts and seborrheic dermatitis are separate conditions that are not related to any of the claimed conditions. The examiner also stated that, because there were no diagnoses for the claimed conditions, aggravation could not be established. See December 2019 VA opinion. The December 2019 VA opinion is inadequate for the following reasons. First, while there was no evidence of skin tags during the December 2019 VA examination, the examiner did not address whether the skin tags manifested during the appeal period were incurred during service or as secondary to the Veteran's service-connected diabetes or eczema disability. The VA examiner also failed to provide the requested opinions regarding the diagnoses of pilar cysts and seborrheic dermatitis also shown during the appeal period, which are current skin disabilities that must be considered in this appeal. Indeed, there remains a question of whether the current diagnoses of pilar cysts and seborrheic dermatitis are progressions of or are otherwise related to the skin tags, cysts, and eczema treated during service. Given the foregoing, the Board finds an addendum opinion is needed. 4. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. In December 2018, the Board remanded this claim to obtain a medical opinion that addressed whether the Veteran's OSA had its onset during service or is related to any incident in service or, in the alternative, is proximately due to or aggravated by his service-connected rhinitis, sinusitis, or hypertension disabilities. The Board specifically requested the examiner address the Veteran's contention that he is unable to properly use his CPAP machine due to his service-connected sinusitis and rhinitis disabilities. In December 2019, a VA physician examined the Veteran, discussed the cause of OSA in general, and opined that the Veteran's OSA is less likely than not aggravated by his service-connected sinusitis, rhinitis, and hypertension. However, the examiner did not address whether the Veteran's OSA is directly related to his military service or is proximately due to his service-connected rhinitis, sinusitis, or hypertension disabilities. The examiner also failed to address whether the symptoms caused by the Veteran's sinusitis and rhinitis impact the use of his CPAP machine. Therefore, the Board finds the directives of the December 2018 Board remand were not substantially complied with, thereby necessitating another remand. See Stegall v. West, 11 Vet. App. 268 (1998). 5. Entitlement to service connection for residuals of rhinoplasty, to include deviated nasal septum, is remanded. In May 2012, the Veteran filed a claim seeking service connection for a deviated nasal septum and rhinoplasty. While the Veteran filed two separate claims for each condition, the Board has combined the two claims, as the evidence of record shows that the scope of each claim involves consideration of the other. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). Indeed, the STRs show the Veteran was diagnosed with nasal septal deviation and obstruction, for which a rhinoplasty was eventually performed during service. See STRs dated November 1977 and April and October 1981. The post-service evidence reflects that the Veteran has consistently reported experiencing nasal obstruction and congestion, post-nasal drip, and recurrent nosebleeds, i.e., epistaxis, for many years since service. See e.g., February 2017 statement from Dr. Gunnlaugsson; July 2019 private treatment record; October 2019 VA treatment record. In December 2019, the VA examiner noted the Veteran's reports of runny nose and nasal congestion since service but stated the Veteran's deviated septum was resolved with the rhinoplasty, as he noted there was no obvious deviation noted during examination. The VA examiner also noted that review of the record "clearly" confirmed that the Veteran fractured his nose during childhood which was the most likely etiology of his prior deviated septum, although he also noted congenital deformity as another potential etiology of the deviation. The examiner opined that, in either case, the septal deviation pre-existed service and was less likely than not incurred in or caused by service. See December 2019 VA opinion. The December 2019 VA opinion is inadequate for the following reasons. First, the examiner did not utilize the correct standards to determine whether the Veteran's deviated septum pre-existed service or was aggravated by service. Indeed, because the STRs do not contain an entrance examination that shows a deviated septum was noted at that time, the Veteran is presumed to have been sound upon entry, and in order to rebut the rebut the presumption of soundness, there must be clear and unmistakable evidence that the Veteran's disability was both preexisting and not aggravated by service. See e.g., Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). There also remains a question of whether any of the Veteran's post-service symptoms are residual symptoms or otherwise attributable to the rhinoplasty performed during service. In this regard, while the October 2013 VA examiner attributed the majority of the Veteran's nasal obstruction to his service-connected allergic rhinitis disability, there is no medical opinion of record that addresses whether the Veteran's recurrent nosebleeds are a result of the in-service rhinoplasty. The Board further notes that, while the December 2019 VA examiner stated that the Veteran's deviated septum was resolved by the in-service rhinoplasty, there is other medical evidence of record that shows the Veteran has been observed to have mild right septal deviation and turbinate hypertrophy during the appeal period, which raises a question of whether any residual nasal deviation is related to the nasal deviation and/or rhinoplasty noted during service. See e.g., February 2017 statement from Dr. Gunnlaugsson and October 2019 VA treatment record. Therefore, an addendum medical opinion is needed that addresses each of the foregoing. 5. Entitlement to service connection for a disability manifested by dyspnea is remanded. At the outset, the Board notes that dyspnea is defined as "breathlessness or shortness of breath; difficult or labored respiration." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 589 (31st ed. 2007). The Veteran initially asserted that he believed his claimed dyspnea was due to exposure to various contaminants during service; however, during the December 2019 VA respiratory examination, the Veteran reported that he began having shortness of breath and coughing in 2001 due to nasal congestion and sinus trouble. The evidence also shows the Veteran has endorsed experiencing dyspnea on exertion while receiving treatment for a heart disability and has continued to attribute his dyspnea to exposure to chemicals during service. See e.g., September 2007 private treatment record and June 2013 VA treatment record. Despite the foregoing, the evidentiary record does not contain a medical opinion that clearly identifies the disability to which the Veteran's claimed dyspnea is related or states whether the claimed dyspnea was incurred during or a result of service. Indeed, while one of the Veteran's private physicians noted that the Veteran's severe dyspnea on exertion is multifactorial, he did not identify its likely etiology. See November 2014 statement from Dr. Modesto. Likewise, while the December 2019 VA examiner noted the Veteran's reports of shortness of breath, he also noted the Veteran did not have a diagnosis of a pulmonary diagnosis or condition and, thus, did not provide a medical opinion regarding direct or secondary service connection, as directed by the Board in its December 2018 remand. See December 2019 VA opinion. Because the evidence of record raises a question of whether the Veteran's claimed dyspnea is due to nasal congestion (presumably caused by his service-connected rhinitis or sinusitis) or his service-connected heart disabilities, and there remains a question of whether his dyspnea was incurred as a result of active service, the Board finds a remand is needed to obtain a medical opinion that addresses these questions. 6. Entitlement to service connection for gout is remanded. In May 2012, the Veteran filed a claim seeking service connection for gout which he asserted was secondary to his service-connected diabetes mellitus disability. In December 2018, the Board remanded this claim to obtain an opinion that addressed whether the Veteran's gout had its onset during service or, in the alternative, is proximately due to or aggravated by any service-connected disability. In December 2019, a VA physician opined that the Veteran's gout is less likely than not incurred in or caused by an in-service injury, event, or illness; however, the examiner did not provide opinions that addressed whether the Veteran's gout was due to or aggravated by any of the service-connected disabilities, as directed. Therefore, an addendum medical opinion is needed. See Stegall, 11 Vet. App. 268 (1998). 7. Entitlement to service connection for a cervical spine disability, claimed as neck pain and cervicalgia, is remanded. 8. Entitlement to service connection for a right knee disability is remanded. In December 2018, the Board remanded these claims to obtain a medical opinion that addressed whether the Veteran's current cervical spine and right knee disabilities had their onset during service or are related to any incident in service or, in the alternative, is proximately due to or aggravated by any service-connected disability. In December 2019, a VA physician examined the Veteran and opined that his cervical spine disability is less likely than not aggravated by any of his service-connected disabilities. See December 2019 VA opinion. The examiner also opined that the Veteran's right knee disability is less likely than not proximately due to or a result of his service-connected back and other disabilities. See December 2019 VA opinion. The examiner did not, however, provide opinions that addressed direct service connection for the cervical spine or right knee disability, whether the cervical spine disability is due to any of the service-connected disabilities, or whether the right knee is aggravated by of the service-connected disabilities, as directed. Therefore, the Board finds the directives of the December 2018 Board remand were not substantially complied with, thereby necessitating another remand. See Stegall, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Obtain a medical opinion regarding the Veteran's right carpal tunnel syndrome disability. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. Following a review of the complete record, the examiner is asked to address the following: (a) Is it as likely as not (a probability of 50 percent) that the Veteran's right carpal tunnel syndrome was incurred or aggravated in service, to include as a result of the duties he performed as an optical laboratory specialist during service? (b) Is it as likely as not (50 percent or greater probability) that the Veteran's right carpal tunnel syndrome is/was caused OR aggravated by his service-connected right lateral epicondylitis disability, to include any manifestations thereof? In answering the foregoing, the examiner must provide an opinion regarding causation and aggravation. Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. In answering each of the foregoing, the examiner must consider the service and post-service medical evidence, as well as the Veteran's statements regarding the onset, nature, and progression of his carpal tunnel disability. A complete, clearly-stated rationale must be provided for each opinion offered. 2. Obtain a medical opinion regarding the Veteran's reported chest pain. Following a review of the complete record, the examiner is asked to address the following: (a) Identify all disabilities manifested by chest pain since May 2012. (b) If no diagnosis is supported by the objective evidence of record or examination, the examiner must address whether the Veteran's complaints of chest pain cause functional loss or impairment that can be considered a disability. The examiner may also wish to address whether the Veteran's chest pain is a symptom or manifestation of his service-connected rhinitis, sinusitis, hypertension, or hypertensive cardiovascular disease. (c) For each disability manifested by chest pain identified above, opine whether it is at least as likely as not (50 percent or higher degree of probability) that the disability was incurred during or as a result of the Veteran's military service, to include the duties he performed therein? (d) Is it as likely as not (50 percent or greater probability) that the Veteran's chest pain is/was caused OR aggravated by his service-connected rhinitis, sinusitis, hypertension, or hypertensive cardiovascular disease disabilities? Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. A clear, well-reasoned rationale must be provided for all opinions, with consideration of the lay and medical evidence. 3. Obtain a medical opinion regarding the Veteran's claimed skin disabilities. Following a review of the complete record, the examiner is asked to address the following: (a) Identify all skin disabilities other than dermatitis manifested by the Veteran since May 2012. For each skin disability identified above, the examiner must address the following: (b) Is it as likely as not (50 percent or higher degree of probability) that the disability was incurred during or as a result of the Veteran's military service, to include his reported inhalation of dust, gases, or other contaminants as a result of his duties during service? (c) Is it as likely as not (50 percent or greater probability) that the Veteran's skin disability is/was caused by his service-connected diabetes or eczema disabilities? (d) Is it as likely as not (50 percent or greater probability) that the Veteran's skin disability is/was aggravated by his service-connected diabetes or eczema disabilities? Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. In answering each of the foregoing, the examiner must consider the service and post-service medical evidence, as well as the Veteran's statements regarding the onset, nature, and progression of his various skin disabilities and the articles submitted by the Veteran in support of his claim. A clear, well-reasoned rationale must be provided for all opinions, with consideration of the lay and medical evidence. 4. Obtain a medical opinion regarding the Veteran's obstructive sleep apnea (OSA) disability. Following a review of the complete record, the examiner is asked to address the following: (a) Is it as likely as not (a probability of 50 percent) that the Veteran's OSA had its onset during service or is otherwise related to his period of active service? (b) Is it as likely as not (50 percent or greater probability) that the Veteran's OSA is/was caused by his service-connected rhinitis, sinusitis, or hypertension disabilities? (c) Is it as likely as not (50 percent or greater probability) that the Veteran's OSA is/was aggravated by his service-connected rhinitis, sinusitis, or hypertension disabilities? (d) Is it as likely as not (50 percent or greater probability) that the symptoms associated with the Veteran's allergic rhinitis and sinusitis, to include nasal obstruction, impact or prevent the use of a CPAP machine such that there is an incremental increase, i.e., aggravation, in his OSA disability? In answering each of the foregoing, the examiner must consider the service and post-service medical evidence, as well as the Veteran's statements regarding the onset and nature of his obstructive sleep apnea. Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. If aggravation of OSA is found, the examiner must attempt to establish a baseline level of severity of OSA prior to aggravation by the service-connected disability. A complete, clearly-stated rationale must be provided for each opinion offered. 5. Request that a medical professional review the claims file and obtain a medical opinion that addresses the following: (a) Is there clear and clear and unmistakable (undebatable) evidence that a deviated nasal septum existed prior to service? If so, identify the evidence. (b) If there is clear and unmistakable evidence that a deviated nasal septum pre-existed service, the examiner must also state if there is clear and unmistakable (undebatable) evidence that the deviated nasal septum was not aggravated during service? In other words, is there undebatable evidence that there was no increase in the deviated nasal septum during service or that any increase in disability was due to the natural progress of the pre-existing condition? (c) If the answer to (a) and (b) is no, the examiner should opine whether it is as likely as not (i.e., probability of 50 percent or higher) that the Veteran's deviated nasal septum was incurred during or as a result of his military service. Regardless of the answers to the foregoing questions, the examiner must also address the following: (e) Is it as likely as not (a probability of 50 percent) that the Veteran's epistaxis, or recurrent nose bleeds following service, are due to or otherwise related to his period of active service, to include the rhinoplasty performed during service? (f) Is it as likely as not (a probability of 50 percent) that any residual deviated nasal septum is due to or otherwise related to the Veteran's period of active service, to include the deviated septum noted during service or the rhinoplasty performed during service? A complete, well-reasoned rationale should be provided for each opinion offered. 6. Obtain a medical opinion regarding the Veteran's claimed dyspnea on exertion. Following a review of the complete record, the examiner is asked to address the following: (a) Is it as likely as not (a probability of 50 percent) that the Veteran's dyspnea on exertion was incurred during or as a result of active service, to include his reported inhalation of dust, gases, or other contaminants as a result of his duties during service? (b) Is it as likely as not (50 percent or greater probability) that the Veteran's dyspnea on exertion is/was caused OR aggravated by his service-connected allergic rhinitis disability, to include any manifestations thereof? (c) Is it as likely as not (50 percent or greater probability) that the Veteran's dyspnea on exertion is/was caused OR aggravated by his service-connected sinusitis disability, to include any manifestations thereof? In answering (b) and (c), the examiner must provide an opinion regarding causation and aggravation. Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the dyspnea prior to aggravation by the service-connected disability. In answering each of the foregoing, the examiner must consider the service and post-service medical evidence, as well as the Veteran's statements regarding the onset, nature, and progression of his dyspnea on exertion. A complete, clearly-stated rationale must be provided for each opinion offered. 7. Obtain a medical opinion regarding the Veteran's gout. Following a review of the complete record, the examiner is asked to address each of the following: (a) Is it as likely as not (50 percent or greater probability) that the Veteran's gout is/was caused by his service-connected disabilities, to specifically include his diabetes mellitus or lumbar spine disabilities and any manifestations thereof? (b) Is it as likely as not (50 percent or greater probability) that the Veteran's gout is/was caused OR aggravated by his service-connected disabilities, to specifically include his diabetes mellitus or lumbar spine disabilities and any manifestations thereof? In answering the foregoing, the examiner must provide an opinion regarding causation and aggravation. Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of gout prior to aggravation by the service-connected disability. In answering each of the foregoing, the examiner must consider the service and post-service medical evidence, as well as the Veteran's statements regarding the onset, nature, and progression of his carpal tunnel disability. A complete, clearly-stated rationale must be provided for each opinion offered. 8. Obtain a medical opinion regarding the Veteran's cervical spine and right knee disabilities. Following a review of the complete record, the examiner is asked to address each of the following: Cervical Spine Is it as likely as not (a probability of 50 percent) that the Veteran's cervical spine disability was incurred during or as a result of his active military service? Is it as likely as not (50 percent or greater probability) that the Veteran's cervical spine disability is/was caused by his service-connected disabilities, to specifically include service-connected diabetes mellitus, sinusitis, allergic rhinitis, hypertension, or lumbar spine disabilities and any manifestations thereof? Right knee - Is it as likely as not (a probability of 50 percent) that the Veteran's right knee disability was incurred during or as a result of his active military service? Is it as likely as not (50 percent or greater probability) that the Veteran's right knee disability is/was aggravated by his service-connected disabilities, to specifically include the service-connected lumbar spine disability and any manifestations thereof? Aggravation means an increase in disability any additional impairment of earning capacity of the nonservice-connected disability. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the diagnosed disability prior to aggravation by the service-connected disability. In answering each of the foregoing, the examiner must consider the service and post-service medical evidence, as well as the Veteran's statements regarding the onset, nature, and progression of his cervical spine and right knee disabilities. A complete, clearly-stated rationale must be provided for each opinion offered. Jenna Brant Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Turnipseed, 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.