Citation Nr: 21028442 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-17 758 DATE: May 11, 2021 ORDER Service connection for an acquired psychiatric disorder, diagnosed as unspecified trauma and stressor-related disorder and major depressive disorder, is granted. REMANDED Entitlement to service connection for obstructive sleep apnea (OSA), to include as due to undiagnosed illness, is remanded. Entitlement to service connection for kidney stones, to include as secondary to type 2 diabetes mellitus, is remanded. Entitlement to service connection for type 2 diabetes mellitus, to include as secondary to kidney stones, is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. FINDING OF FACT The evidence as to whether the Veteran's acquired psychiatric disorder, diagnosed as unspecified trauma and stressor-related disorder and major depressive disorder, is causally related to his military service is at least in equipoise. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for an acquired psychiatric disorder, diagnosed as unspecified trauma and stressor-related disorder and major depressive disorder, have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from July 2005 to February 2007, to include service in Djibouti, Africa. He also served on periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) in the U.S. Army Reserve, to include periods of ACDUTRA from November 1986 to March 1987 and for 13 days from August 2, 2009. These matters come to the Board of Veterans' Appeals (Board) on appeal from September 2014 and April 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. In March 2020, the Veteran and his wife testified at a Board video-conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. This case was previously before the Board in June 2020, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. In the remand, the Board directed the AOJ to ask the Veteran to identify and provide appropriate releases for records of any private treatment he had received for the issues on appeal, to include the provider(s) who referred him for a sleep study in 2010, and to obtain updated VA treatment records. The remand also directed the AOJ to afford the Veteran new VA examinations and opinions with respect to each of the issues addressed herein. Because the development sought with respect to the Veteran's claims for service connection for OSA, kidney stones, diabetes, a back disability, and his knee disabilities was not fully completed, a further remand as to those issues is required. Stegall v. West, 11 Vet. App. 268 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order.) The Board notes that the Veteran's claim of entitlement to service connection for a left shoulder disability was also previously on appeal. In a January 2021 rating decision, the AOJ granted service connection for left shoulder strain and rotator cuff tendonitis. As the January 2021 decision represents a full grant of the benefits sought with respect to that issue, that matter is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). Entitlement to service connection for an acquired psychiatric disorder As noted above, in its June 2020 remand, the Board directed the AOJ to ask the Veteran to identify and provide appropriate releases for records of any private treatment he has received for the issues on appeal and to obtain updated VA treatment records. It also directed the AOJ to afford the Veteran a VA examination in connection with his claim for service connection for an acquired psychiatric disorder. In July 2020, the AOJ sent the Veteran a letter asking him to identify and provide an appropriate release for records of any private treatment. Later that same month, the Veteran provided a release and identified K.H., M.D., as a private provider who had treated him for the issues on appeal. The AOJ obtained updated records from Dr. H. later that same month, and it obtained updated VA treatment records in August 2020. It afforded the Veteran a VA examination in November 2020. The Board finds that with respect to the Veteran's claim for service connection for an acquired psychiatric disorder, the AOJ at least substantially complied with the Board's remand directives. See Stegall, supra. The Veteran seeks to establish service connection for an acquired psychiatric disorder. He has contended that he has PTSD that was incurred in or caused by service, and that three stressors caused his PTSD. In a February 2015 statement in support of claim, he described one of these stressors as being threatened at gunpoint by a chief who insisted that he and his fellow service members leave an area to which they had gone to build wells while serving in Africa. At a March 2015 VA examination, he described two additional stressors including witnessing soldiers being killed in a helicopter crash and witnessing local children being exposed to the horrors of war. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). Under applicable law, disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 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) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). 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 (1990). The Veteran was afforded a VA examination in connection with his claim in March 2015. The examiner diagnosed unspecified anxiety disorder but found that the Veteran did not meet the criteria for a diagnosis of PTSD. The examiner considered the Veteran's stressors of witnessing soldiers being killed in a helicopter crash and witnessing children being exposed to the horrors of war, but found that neither of those events met the criteria for a diagnosis of PTSD. The examiner also rendered a negative nexus opinion as to the Veteran's unspecified anxiety disorder, reasoning in an April 2015 addendum opinion that there was no evidence of complaints of, evaluation for, or any treatment of any mental or emotional complaints or symptoms during service. The Veteran was afforded another VA examination in November 2020. The examiner considered PTSD but found that the Veteran's symptoms did not meet the criteria for a diagnosis of PTSD. Rather, she diagnosed unspecified trauma and stressor-related disorder and major depressive disorder, recurrent and moderate. The examiner noted that the Veteran served during the Iraq War from 2006 to 2007 in Djibouti, Africa, and that he was stationed there for water-well drilling and monitoring terrorist movement. She further noted that he was not involved in combat but that he was exposed to hostile activity and tense moments. The examiner considered the Veteran's stressors of being threatened at gunpoint by a chief and witnessing soldiers being killed in a helicopter crash, but noted that the Veteran did not actually witness the helicopter crash itself. The examiner found that neither stressor met the criteria for a PTSD diagnosis, and remarked that there were no findings, signs, or symptoms to support that diagnosis. She offered a positive nexus opinion, however, as to the Veteran's diagnoses of unspecified trauma and stressor-related disorder and major depressive disorder. She reasoned that while the Veteran did not meet the full criteria for a PTSD diagnosis, his symptoms of anxiety suggestive of unspecified trauma and stressor-related disorder and his chronic pain resulted in some impairment in work and marital/family relationships as revealed in the medical records reviewed, and that the onset of his symptoms occurred in response to the trauma event as noted in the records. She further stated in the diagnostic section of her report that the Veteran's major depressive disorder was secondary to his unspecified trauma and stressor-related disorder which was the result of being held at gunpoint while in service. The Board finds the November 2020 VA examiner's opinion to be the most probative evidence on the question of whether the Veteran's acquired psychiatric disorder was incurred in service and affords it significant weight. The opinion was based on review of the Veteran's record including his reports, military records, and mental health treatment records, with a thorough rationale provided for the opinion given. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). While acknowledging that the March 2015 VA examiner offered a negative nexus opinion, the Board finds that the evidence as to whether the Veteran has an acquired psychiatric disorder that was incurred in or caused by service is, at the very least, in equipoise. Under the benefit of the doubt rule, where there exists an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the Veteran shall prevail upon the issue. Ashley v. Brown, 6 Vet. App. 52, 59 (1993); see also Massey v. Brown, 7 Vet. App. 204, 206-07 (1994). In light of the positive evidence regarding the diagnoses of unspecified trauma and stressor-related disorder and major depressive disorder, the occurrence of an in-service event, and a link between that event and the onset of the Veteran's psychiatric symptoms, service connection is granted. REASONS FOR REMAND 1. Entitlement to service connection for OSA, to include as due to undiagnosed illness, is remanded. The Veteran contends that his OSA was incurred in or aggravated by service. Specifically, he contended in a January 2015 submission that he had had OSA as far back as 2010 when he was referred for a sleep study. He also stated in a December 2018 submission that in 2007 magnetic resonance imaging (MRI) was performed and a request for a sleep study revealed the need for a continuous positive airway pressure (CPAP) machine for treatment of OSA. In support of his claim, the Veteran submitted a September 2014 statement from Dr. H. in which she stated that he was referred to a sleep specialist in 2010 for evaluation of sleep apnea. As noted above, in the June 2020 remand, the Board directed the AOJ to assist the Veteran in obtaining private treatment records, to include those from the provider who referred him for a sleep study in 2010. It also directed the AOJ to afford the Veteran a VA examination in connection with his claim, and instructed the examiner specifically to consider a January 2007 post-deployment questionnaire in which the Veteran described that he was still tired after sleeping; January 2016 and February 2018 lay statements of the Veteran's wife and a fellow service member; and a March 2018 opinion from Dr. H. In his July 2020 response to the AOJ regarding private treatment records, the Veteran indicated that Dr. H. had treated him from March 2007 to July 2020. The Board notes that the earliest record in the claims file from Dr. H. at the time of the remand was from May 2014. Subsequent to the remand, the AOJ obtained only updated records from Dr. H (covering the date range of September 2019 to April 2020). Inasmuch as the Veteran indicated in his July 2020 response that he began treating with Dr. H. in 2007, and her referral for a sleep study in 2010 constitutes an allegation that the Veteran had symptoms of OSA prior to his April 2014 diagnosis, the Board finds that the RO did not substantially comply with the remand directives regarding records development as it relates to his claim for service connection for OSA. See Stegall, supra. On remand, efforts should be made to obtain a complete copy of Dr. H.'s private treatment records, with particular emphasis on those from March 2007 to May 2014. In August 2020, the Veteran submitted a sleep apnea Disability Benefits Questionnaire (DBQ) from a private provider, W.J., M.D. dated in July 2020. Dr. J. stated that the Veteran has OSA and cited to the April 2014 sleep study, but he did not indicate a date of diagnosis otherwise. He also stated that the Veteran had had witnessed apneas since 2005 and daytime sleepiness since 2006. The Board finds that Dr. J.'s July 2020 DBQ is insufficient to support an award of service connection at present. Dr. J. did not specify or explain who witnessed the apneas or daytime sleepiness, and his report is not supported by any medical evidence of record. While the April 2014 sleep study demonstrates that the Veteran was referred for the study by both Drs. J. and H., the claims file contains no records from Dr. J. which might be used to support his assertion that the Veteran had had witnessed apneas since 2005. While both providers referred the Veteran for a sleep study in 2014, review of Dr. H.'s records does not indicate that the two providers practice at the same facility, and Dr. J.'s address on the July 2020 sleep apnea DBQ does not match that of Dr. H. While the Veteran did not identify Dr. J. as a private provider who had treated him for OSA in his July 2020 response to the AOJ regarding private treatment providers, the Board finds that his submission of the July 2020 DBQ reasonably identifies Dr. J. as a provider whose records are pertinent to the issue on appeal. As such, the AOJ should have made attempts to obtain copies of his records. The AOJ afforded the Veteran a new VA examination in November 2020. The examiner offered a negative nexus opinion, noting that the Veteran was not diagnosed with OSA until 2014. She stated that the 2007 post-deployment description of tiredness after sleeping could have many etiologies and was not definitive for sleep apnea, that the statements of Dr. H., the Veteran's wife, and his fellow service member observed that the Veteran had symptoms of OSA but did not show that the symptoms occurred while the Veteran was on active duty or active reserve, and that the Veteran was diagnosed with OSA in 2014 and his last deployment was in 2009. She further noted that the Veteran stated that he had a sleep study in 2010 but was not given the results, and that there was no evidence of that study in the medical records. The examiner also opined that OSA, which clearly and unmistakably existed prior to service was clearly and unmistakably not aggravated beyond its natural progression by any in-service injury, event, or illness, that there was no evidence that OSA existed prior to service, and that there was no evidence that it was related to a disease or injury incurred in or aggravated during a period of ACDUTRA or INACDUTRA. In light of the fact that Dr. H.'s earlier records might contain the results of a 2010 sleep study, the Board finds that a remand for an addendum opinion with consideration of Dr. H.'s complete records is warranted. At the very least, the examiner should consider Dr. H.'s September 2014 statement that the Veteran was referred for a sleep study in 2010, even if no sleep study was actually performed. The examiner should also consider Dr. J.'s July 2020 sleep apnea DBQ. 2. Entitlement to service connection for kidney stones, to include as secondary to type 2 diabetes mellitus, is remanded. 3. Entitlement to service connection for type 2 diabetes mellitus, to include as secondary to kidney stones, is remanded. The Veteran contends that he developed kidney stones during a 13-day period of ACDUTRA from August 2, 2009, while serving at Fort Jackson, South Carolina. Regarding diabetes, he contended in his January 2015 notice of disagreement (NOD) that during his tenure in the military his civilian records indicated an elevated amount of sugar in his blood work, that military rations were not intended for people with borderline sugar levels, and that the rations added to (aggravated) his already elevated blood sugar levels. He also contends that his diabetes is secondary to kidney stones and submitted October 2011 and November 2011 medical treatises indicating that kidney stones may increase the risk of developing diabetes. He further contends that his kidney stones are secondary to his diabetes and in December 2020 he submitted an undated article indicating that diabetes can lead to kidney stones along with a 2006 article on diabetes and kidney stone formation. In its April 2020 remand, the Board directed the AOJ to afford the Veteran a VA examination in connection with his claims. The Board specifically instructed the examiner to consider the March 2018 opinion from Dr. H. and the Veteran's contention that rations in service aggravated his diabetes. The remand also noted that if the examiner found that the Veteran's kidney stones were service-related, then he or she should also offer an opinion on secondary service connection with consideration of the October 2011 and November 2011 medical treatises and Dr. H.s March 2018 opinion. The Veteran was afforded a VA examination in November 2020. The examiner offered a negative nexus opinion as to kidney stones, noting the Veteran's report that he was treated for kidney stones on active duty, but stating that medical records did not support treatment for kidney stones while the Veteran was on active duty. She addressed Dr. H.'s March 2018 statement but found that it did not state that the Veteran was diagnosed with or treated for kidney stones while on active duty. She further opined that the Veteran's kidney stones, which clearly and unmistakably existed prior to service, were clearly and unmistakably not aggravated beyond their natural progression by an in-service injury, event, or illness, reasoning that kidney stones are small hard clusters of crystal deposits, and that they are formed when there is an excess of a particular calcium or uric acid in the system which cannot be diluted by the body. She stated that the natural progression is passing of the stones, or if progressed, surgical intervention. She opined that the medical records did not support aggravation of kidney stones beyond their natural progression, and that there was no evidence that the Veteran's kidney stones and/or diabetes were related to a disease or injury incurred in or aggravated during a period of active duty for training or during a period of inactive duty for training. The November 2020 examiner also offered a negative nexus opinion as to diabetes, reasoning that kidney stones do not cause diabetes, but that diabetes might increase the risk of having kidney stones. She stated further that diabetes is a medical condition that is associated with high blood sugar, that it results from lack of or insufficiency of hormone insulin, and that there are two types of diabetes. She noted that the first type was an autoimmune disease that came on suddenly in childhood or young adulthood, and that studies showed that having the second type more than doubled an individual's chances of having kidney stones. She explained that kidney stones formed when urine has high amounts of things like calcium, oxalate, and uric acid, and that insulin resistance from diabetes can raise the levels of calcium in a person's urine, which can make kidney stones more likely. The examiner also offered a negative nexus opinion regarding aggravation of diabetes, reasoning that based on the provided medical records, physical, and history, there was no evidence to suggest that the Veteran's diabetes was aggravated by kidney stones. Regarding kidney stones, the Board finds that the November 2020 VA examiner's opinion is inconsistent with the evidence of record, which shows that the Veteran was treated for kidney stones during the 13-day period of ACDUTRA that began on August 2, 2009. Her opinion regarding whether kidney stones are secondary to diabetes does not address the Veteran's case specifically, and addresses the issue in terms of possibility, rather than probability (i.e., "diabetes can raise the levels of calcium in a person's urine, which can make kidney stones more likely"). Regarding diabetes, the examiner does not appear to have considered the Veteran's contention that rations in service aggravated his diabetes. Additionally, her opinion that diabetes was not aggravated by kidney stones is not supported by any rationale. Finally, because the Veteran submitted articles regarding the relationship between diabetes and kidney stones subsequent to the November 2020 VA examination, the examiner did not have the benefit of reviewing those articles. Under the circumstances, an addendum opinion is warranted. 4. Entitlement to service connection for a back disability is remanded. The Veteran contends that his back disability was incurred in or caused by service. In the June 2020 remand, the Board directed the AOJ to afford the Veteran a VA examination in connection with his claim. The remand specifically instructed the examiner to consider the Veteran's in-service reports of back pain in May 1993, October 2001, and December 2001 service treatment records (STRs). The Veteran was afforded a VA examination in November 2020. The examiner found that the Veteran had current diagnoses of degenerative arthritis of the spine and intervertebral disc syndrome (IVDS). Her report also noted that a November 2018 private treatment record showed a diagnosis of osteoarthritis of the lumbar spine with radiculopathy. The examiner offered a negative nexus opinion, reasoning that the medical records showed an acute episode of back pain in 1993, but that there was no further documentation for that condition while the Veteran was in the military. She also cited to Dr. H.'s March 2018 opinion but stated that it did not indicate when the Veteran first began treatment for a back condition. The examiner further opined that the Veteran's back disability, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness, reasoning that there was no evidence that the Veteran's back condition was related to any disease or injury incurred in or aggravated during a period of active duty for training or during a period of inactive duty for training. The Board notes that the November 2020 VA examiner failed to address the October 2001 and December 2001 STRs showing in-service reports of back pain. Under the circumstances, an addendum opinion is warranted. 5. Entitlement to service connection for a right knee disability is remanded. 6. Entitlement to service connection for a left knee disability is remanded. The Veteran contends that his knee disabilities were incurred in or caused by service. In the June 2020 remand, the Board directed the AOJ to afford the Veteran a VA examination in connection with his claim. It specifically instructed the examiner to consider October 2001, December 2001, May 2004, and September 2008 STRs in which the Veteran reported knee pain, and the March 2018 opinion of Dr. H. The Veteran was afforded a VA examination in connection with his claim in November 2020. The examiner diagnosed bilateral knee strains. She offered a negative nexus opinion regarding the right knee, reasoning that while the Veteran was given a diagnosis of chronic knee pain in 2004, that was prior to his enlistment in the military. She stated that there were no complaints of, treatment for, or diagnosis of a knee condition while the Veteran was in active military service, noting that he complained of knee pain in 2008, more than a year after leaving the military. She also offered a negative nexus regarding the left knee, stating that her opinion was based on the provided medical records, history, and physical. The Board notes that the November 2020 VA examiner did not consider the October 2001 or December 2001 STRs, or the March 2018 opinion of Dr. H. Additionally, the examiner provided no rationale regarding her opinion as to the left knee. Under the circumstances, an addendum opinion is warranted. These matters are REMANDED for the following action: 1. Ask the Veteran to identify, and provide appropriate releases for, any private care providers who have examined him for a sleep disorder (to include records from Dr. H. from March 2007 to May 2014 at Piedmont Healthcare in Atlanta, Georgia, and from Dr. J. in Atlanta, Georgia) or who may otherwise possess new or additional evidence pertinent to the issues remaining on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact, and the Veteran and his representative should be notified. 2. Obtain copies of records pertaining to any VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 3. After the foregoing development has been completed to the extent possible, arrange to provide the record on appeal to the VA examiner who provided an opinion with respect to the etiology of the Veteran's OSA in November 2020 for an addendum opinion. The examiner should review the expanded record. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the Veteran's OSA had its onset in, or is otherwise related to, his period of active service. If the examiner finds that the Veteran's OSA did not have its onset in, or is otherwise related to, his period of active service, the examiner should offer a further opinion as to the likelihood that the Veteran's OSA (1) is related to a disease or injury incurred in or aggravated during a period of active duty for training (ACDUTRA) or (2) is related to an injury incurred in or aggravated during a period of inactive duty for training (INACDUTRA) (the Board parenthetically notes that only injuries, and not diseases, are recognized under 38 U.S.C. § 101(24) as the basis for establishing service-connection related to periods of INACDUTRA). In so doing, the examiner should consider the results of a 2010 sleep study, if any, and Dr. H.'s September 2014 statement that the Veteran was referred for a sleep study in 2010, even if it the study was never performed. She should also consider Dr. J.'s July 2020 sleep apnea DBQ indicating that the Veteran had witnessed apneas in 2005 and daytime sleepiness in 2006. If the November 2020 VA examiner is no longer employed by VA or is otherwise unable to provide the requested opinions, arrange to obtain the requested information from another qualified examiner. The need for an in-person and/or telephonic or video interview of the Veteran is left to the discretion of the examiner(s) selected to offer the requested opinions. A complete medical rationale for all opinions expressed must be provided. 4. Also arrange to provide the record on appeal to the VA examiner who provided an opinion with respect to the etiology of the Veteran's kidney stones and diabetes in November 2020 for an addendum opinion. The examiner should review the expanded record. After reviewing the record, the examiner should provide an opinion as to whether it is at least as likely as not that the Veteran's kidney stones and/or diabetes had their onset in, or are otherwise related to, the Veteran's period of active service. If the examiner finds that the Veteran's kidney stones and/or diabetes did not have their onset in, or are otherwise related to, a period of active service, the examiner should offer a further opinion as to the likelihood of whether the Veteran's kidney stones and/or diabetes (1) are related to a disease or injury incurred in or aggravated during a period of active duty for training (ACDUTRA) or (2) are related to an injury incurred in or aggravated during a period of inactive duty for training (INACDUTRA) (the Board parenthetically notes that only injuries, and not diseases, are recognized under 38 U.S.C. § 101(24) as the basis for establishing service-connection related to periods of INACDUTRA). In so doing, the examiner should consider and address the Veteran's contention that his diabetes was aggravated by rations in service, as well as the 2006 article and undated article regarding diabetes and kidney stones that the Veteran submitted in December 2020. If the examiner finds that the Veteran's kidney stones are service related, she should be asked to provide an opinion as to whether it is at least as likely as not that the Veteran's diabetes was (a) caused or (b) aggravated (i.e., worsened beyond natural progression) by his kidney stones. If the examiner finds that the Veteran's diabetes is service related, she should be asked to provide an opinion as to whether it is at least as likely as not that the Veteran's kidney stones were (a) caused or (b) aggravated by his diabetes. If the November 2020 VA examiner is no longer employed by VA or is otherwise unable to provide the requested opinions, arrange to obtain the requested information from another qualified examiner. The need for an in-person and/or telephonic or video interview of the Veteran is left to the discretion of the examiner(s) selected to offer the requested opinions. A complete medical rationale for all opinions expressed must be provided. 5. Arrange, further, to provide the record on appeal to the VA examiner who provided an opinion with respect to the etiology of the Veteran's back disability in November 2020 for an addendum opinion. The examiner should review the expanded record. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's back disability had its onset in, or is otherwise related to, the Veteran's period of active service. If the examiner finds that the Veteran's back disability did not have its onset in, or is otherwise related to, a period of active service, the examiner should offer a further opinion as to the likelihood that Veteran's back disability (1) is related to a disease or injury incurred in or aggravated during a period of active duty for training (ACDUTRA) or (2) is related to an injury incurred in or aggravated during a period of inactive duty for training (INACDUTRA) (the Board parenthetically notes that only injuries, and not diseases, are recognized under 38 U.S.C. § 101(24) as the basis for establishing service-connection related to periods of INACDUTRA). In so doing, the examiner should consider and address the Veteran's in-service reports of back pain in the May 1993, October 2001, and December 2001 STRs. If the November 2020 VA examiner is no longer employed by VA or is otherwise unable to provide the requested opinions, arrange to obtain the requested information from another qualified examiner. The need for an in-person and/or telephonic or video interview of the Veteran is left to the discretion of the examiner(s) selected to offer the requested opinions. A complete medical rationale for all opinions expressed must be provided. 6. Also arrange to provide the record on appeal to the VA examiner who provided opinions with respect to the etiology of the Veteran's knee disabilities in November 2020 for an addendum opinion. The examiner should review the expanded record. After reviewing the record, the examiner should offer an opinion as to whether it is at least as likely as not that the Veteran's right and left knee disabilities had their onset in, or are otherwise related to, the Veteran's period of active service. If the examiner finds that the Veteran's knee disabilities did not have their onset in, or are otherwise related to, a period of active service, the examiner should offer a further opinion as to the likelihood of whether the Veteran's knee disabilities (1) are related to a disease or injury incurred in or aggravated during a period of active duty for training (ACDUTRA) or (2) are related to an injury incurred in or aggravated during a period of inactive duty for training (INACDUTRA) (the Board parenthetically notes that only injuries, and not diseases, are recognized under 38 U.S.C. § 101(24) as the basis for establishing service-connection related to periods of INACDUTRA). In so doing, the examiner should consider and address the October and December 2001, May 2004, and September 2008 STRs in which the Veteran reported knee pain, and the March 2018 opinion of Dr. H. If the November 2020 VA examiner is no longer employed by VA or is otherwise unable to provide the requested opinions, arrange to obtain the requested information from another qualified examiner. The need for an in-person and/or telephonic or video interview of the Veteran is left to the discretion of the examiner(s) selected to offer the requested opinions. A complete medical rationale for all opinions expressed must be provided. 7. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the issues remaining on appeal should be re-adjudicated based on the entirety of the evidence. If any benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Oldroyd, 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.