Citation Nr: 21030386 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 13-27 767 DATE: May 18, 2021 ORDER Entitlement to service connection for inflammatory arthritis (previously characterized as reactive arthritis and rheumatic arthritis) is denied. Entitlement to compensation under 38 U.S.C. § 1151 for a kidney disorder is denied. Entitlement to compensation under 38 U.S.C. § 1151 for a leukocyte disorder is denied. REMANDED Entitlement to service connection for a lumbosacral spine disorder is remanded. FINDINGS OF FACT 1. The Veteran's inflammatory arthritis, diagnosed as gout/gouty arthritis, did not manifest in service or within one year thereafter and is not otherwise related to a period of qualifying service. 2. The Veteran does not have any additional kidney disability as a result of the period of Department of Veterans Affairs (VA) treatment for which he claims he was over-prescribed Allopurinol and Colchicine for his gout. 3. The Veteran does not have a current leukocyte disorder, and he does not have any additional leukocyte disability as a result of the period of VA treatment for which he claims he was over-prescribed Allopurinol and Colchicine for his gout. CONCLUSIONS OF LAW 1. The criteria for service connection for inflammatory arthritis have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 1131; 38 C.F.R. §§ 3.6, 3.102, 3.159, 3.303, 3.307, 3.309. 2. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for a kidney disorder have not been met. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.102, 3.159, 3.361. 3. The criteria for entitlement to compensation under 38 U.S.C. § 1151 for a leukocyte disorder have not been met. 38 U.S.C. § 1151; 38 C.F.R. §§ 3.102, 3.159, 3.361. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1971 to August 1974. He had subsequent service in the United States Army Reserve, which included a period of active duty for training from January 1987 to July 1987. This case comes before the Board of Veterans' Appeals (Board) on appeal from August 2011 and December 2012 rating decisions. A hearing was held before the undersigned Veterans Law Judge in September 2016. A transcript of the hearing is of record. In an October 2020 letter, the Board notified the Veteran that he may request a virtual tele-hearing instead of waiting for a travel board hearing; however, that letter was sent in error, as the record shows that the Veteran had not requested a second hearing. See Quinn v. Wilkie, 31 Vet. App. 284 (2019) and October 2020 Board memorandum. Based on the foregoing, there is no outstanding hearing request. His 2016 testimony has been considered by the undersigned in making this decision. In a February 2017 decision, the Board determined that the inflammatory arthritis and lumbar spine disorder (now lumbosacral spine based on the more recent diagnoses and the Veteran's contentions) claims, separated and recharacterized as such for reasons detailed in that decision, were to be reviewed on a de novo basis under 38 C.F.R. § 3.156(c)(1) and denied other claims that were on appeal. The Board also remanded the remaining claims at that time for further development. In a July 2018 decision, the Board denied another claim that was on appeal and remanded the above claims, as well as another claim now resolved, for further development. The requested development was completed, and the case has returned to the Board for appellate review. The Veteran is now represented by the above-named accredited representative, and a VA Form 21-22a is of record. The Board also fulfilled a Privacy Act request in February 2021 by providing the Veteran's current representative from the same firm with a copy of the complete claims file. Finally, the Board notes that updated VA treatment records that were added to the claims file after the October 2019 supplemental statement of the case (SSOC) contain the same information as that established in other records reviewed by the agency of original jurisdiction (AOJ) for the claims decided herein. As such, the records do not materially alter the outcome of the case, and a remand for initial AOJ review for the claims is not necessary. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant are to be avoided). Law and Analysis Initially, the Board acknowledges the Veteran's contention that someone tampered with his service records, resulting in missing records. See September 2016 Bd. Hrg. Tr. Nevertheless, the Board finds that the complete service records are associated with the claims file. In this regard, the National Personnel Records Center (NPRC) provided service treatment records and service personnel records in responses to requests from the AOJ; the second request was for the complete service records. See May 1976 and November 2014 3101 responses. Both responses included active duty and Reserve records, and there are joint complaints contained in some service treatment records. Based on the foregoing, the Board will proceed as though the complete service records are associated with the claims file. The Veteran's non-specific contention is insufficient to rebut the presumption of regularity as to the storage of his records as delivered by the service department. See Ashley v. Derwinski, 2 Vet. App. 307 (1992) (discussing presumption of regularity for official acts of public officers, absent clear evidence to the contrary). Neither the Veteran nor his representatives have raised any other issues with the duty to notify or duty to assist with regard to the claims decided herein. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). I. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). A veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable. 38 U.S.C. § 101(2); 38 C.F.R. § 3.1(d). The term "active military, naval, or air service" includes active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C. § 101(24); 38 C.F.R. §§ 3.6(a)-(d). In addition, for veterans who have served 90 days or more of continuous active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In this case, this presumption is applicable to the Veteran's period of active duty service but not his period of ACDUTRA because veteran status has not been established. See Smith v. Shinseki, 24 Vet. App. 40 (2010) and Hill v. McDonald, 28 Vet. App. 243 (2016). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As arthritis is considered to be a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and 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; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that service connection is not warranted for inflammatory arthritis. The Veteran has essentially contended that in-service symptoms during his first period of service were early manifestations of current gouty arthritis problems. He has also contended that this problem is related to his in-service duties, such as shoveling. See, e.g., September 2016 Bd. Hrg. Tr. at 3-6; August 2010 new claim (indicated that arthritic "connective tissue disease" started to manifest in May 1973). The post-service evidence shows that the Veteran has a current inflammatory arthritis diagnosis of crystal-proven gout/gouty arthritis (hereinafter referred to as gout) in multiple joints. See, e.g., VA treatment records from May 2002 and January 2019 (historical laboratory report with gout crystals noted in more recent record as basis for current diagnosis); VA examination reports from January 2011 (noted no diagnosis of rheumatoid arthritis with rheumatoid factor laboratory tests always negative during treatment) and May 2017 (continued gout diagnosis with notations from VA treatment records). The Board notes that the Veteran is competent to report observable symptomatology and events, such as a recollection of the onset of joint pain. Nevertheless, the Board finds that his gout did not manifest in service. The Veteran's relevant body systems were found to be normal at the time of the June 1971 entrance examination, and he denied having a history of relevant symptoms on the corresponding report of medical history. His service treatment records show complaints referrable to the joints without a diagnosis of gout. See, e.g., service treatment records from May 1973 (report of pain in the thighs and veins; lower extremities negative on examination), June 1973 (reported joints hurting for four days along with headache and nausea; diagnosis of viral syndrome), July 1973 (reported back pains starting two days prior after heavy lifting; impression of lumbosacral strain), and December 1973 (reported strained muscle of the right shoulder from lifting weights). The Veteran's relevant body systems were again found to be normal at the time of the June 1974 separation examination. Similarly, the Veteran's relevant body systems were found to be normal at the time of the May 1977 Reserve entrance examination and the July 1986 Reserve entrance examination (several months before the period of ACDUTRA service), and he denied having a history of relevant symptoms on the corresponding reports of medical history. The Veteran also reported that he was discharged from the first Reserve service period in August 1978 in the 1986 Reserve report of medical history, which is consistent with the service records. See August 1978 discharge orders (first period of Reserve service); see also, e.g., October 1986 VA general medical examination report for original compensation claim (musculoskeletal system noted to be within normal limits with no relevant joint-related complaints; right index finger is already service-connected based on an in-service injury). To determine that a chronic disease was "shown in service," the disease identity must be established and the diagnosis not subject to legitimate question. 38 C.F.R. § 3.303(b); Walker, supra. The service treatment records do not show that the Veteran had gout during service. Therefore, chronicity is not established in service. Moreover, the record contains no indication that the disorder manifested to a compensable degree within one year of the Veteran's period of active duty service from June 1971 to August 1974 for chronic presumptive service connection. To the extent that the Veteran has contended that he has experienced ongoing gout symptoms beginning during his active duty service, the Board finds that such a contention is not consistent with the contemporaneous record as discussed above and is outweighed by the affirmative evidence showing otherwise. See also Curry v. Brown, 7 Vet. App. 59, 68 (1994) (holding that contemporaneous evidence has greater probative value than history as reported by a claimant). In addition, the record shows conflicting reports as to the ongoing nature of the Veteran's symptoms since service. For example, he filed service connection claims for other disorders and nonservice-connected pension benefits in multiple claims beginning in 1985 before first filing a compensation claim for a systemic arthritis disorder in 2005. In a November 2000 claim processed as one for nonservice-connected pension (still after other claims for compensation for other disorders), the Veteran did indicate he had severe gout joint pains, but he also noted that the problem began in March 1998. The Veteran also reported during VA treatment that he started having such problems in the late 1990s. See, e.g., VA treatment records from April 1998 (noted symptoms in the right knee for two weeks), June 1999 (appointment for polyarthritis with elevated uric acid assessed as gout; noted Veteran stated that he felt well until one year ago before developing joint symptoms, including in the right knee). Based on the foregoing, the Board finds that the Veteran's current statements are not reliable or credible evidence to establish a history of ongoing symptoms in or since service. In addition to the lack of evidence showing that gout manifested in service or within close proximity thereto, the weight of the evidence of record does not relate the current disorder to the Veteran's military service. An April 2002 VA examination report for the nonservice-connected pension claim shows diagnoses including gout (confirmed shortly thereafter on the laboratory testing noted above) but does not address the question of etiology. The January 2011 VA examiner diagnosed the Veteran with gout with no evidence of rheumatoid arthritis, as well as a lumbar strain (a diagnosis addressed with the separate lumbosacral spine disorder claim); however, the examiner did not provide a complete etiology opinion as to the gout. In summary, the Board finds that these medical opinions are not adequate to decide the case. See also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The May 2017 VA examiner determined that it was less likely than not that the Veteran's joint symptoms while in the service were related to his current gout diagnosed many years after he left active duty. In so finding, he noted that the gout was diagnosed in the late 1990s, and as confirmed by the records and the Veteran's report at the examination, his symptoms began consistently one year earlier in 1998. The examiner further explained that the Veteran did not have any joint symptoms consistent with gout in the service treatment records and that gout is due to increased uric acid levels and not strains/sprains or physical labor. In a July 2017 VA medical opinion, the same examiner confirmed the earlier opinion, noting that the in-service joint symptoms were transient and not indicative of gout. The examiner further noted that the medical evidence of gout was not present in service or soon afterwards, again noting that gout is a result of elevated uric acid and not wear and tear on the joints or an overuse condition. The Board finds that these 2017 VA medical opinions are highly probative, as they are based on a review of the claims file and are supported by rationale. The Board has considered the Veteran's statements, including his contention during his initial arthritis claim that he has reactive/rheumatoid arthritis from in-service illness. See, e.g., February 2005 and August 2006 written statements; August 2010 new claim. Although lay persons are competent to provide opinions on some medical issues, as to the specific issues in this case, the diagnosis of any inflammatory arthritis and the etiology of the disease, falls outside the realm of common knowledge of a lay person, particularly in light of the delayed onset and the internal processes involved. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, even assuming that the Veteran is competent to opine on these medical matters, the Board finds that the VA examiner's opinions are more probative, as they were provided by a medical professional with knowledge, training, and expertise and is supported by rationale. The VA examiner reviewed the claims file and considered the Veteran's reported history and lay statements. Based on the foregoing, the Board finds that the weight of the evidence is against the Veteran's claim. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. II. Section 38 U.S.C. § 1151 A veteran who suffers disability resulting from hospital care or medical or surgical treatment provided by a VA employee or in a VA facility is entitled to compensation for the additional disability in the same manner as if such additional disability were service-connected if the additional disability was not the result of willful misconduct and was proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing that treatment, or an event not reasonably foreseeable. 38 U.S.C. § 1151(a)(1)(A), (B); 38 C.F.R. § 3.361(a)-(d); Viegas v. Shinseki, 705 F.3d 1374, 1377-78 (Fed. Cir. 2013). The purpose of the statute is to award benefits to those veterans who were disabled as a result of VA treatment or vocational rehabilitation. 38 U.S.C. § 1151(a). First, there must be evidence of additional disability, as shown by comparing the veteran's condition before and after the VA medical care in question. 38 C.F.R. § 3.361(b). To determine whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care, medical or surgical treatment, examination, training and rehabilitation services, or compensated work therapy (CWT) program upon which the claim is based to the veteran's condition after such care, treatment, examination, services, or program has stopped. VA considers each body part or system separately. The additional disability must not be the result of the veteran's willful misconduct. 38 U.S.C. § 1151(a); 38 C.F.R. § 3.301(c)(3). Second, the additional disability must be caused by hospital care, medical or surgical treatment, examination, training and rehabilitation services, or CWT program furnished the veteran by VA. 38 C.F.R. § 3.361(c). In order for additional disability to be compensable under 38 U.S.C. § 1151, the additional disability must have been actually caused by, and not merely coincidental to, hospital care, medical or surgical treatment, or medical examination furnished by a VA employee or in a VA facility. Merely showing that a veteran received care, treatment, or examination and that the veteran has an additional disability does not establish cause. 38 C.F.R. § 3.361(c)(1). The Federal Circuit has held that the causation element of section 1151 is satisfied not only when an injury is "directly" or "actually" caused by the actions of VA employees, but also where an injury occurs in a VA facility resulting from VA's negligence. Viegas, 705 F.3d at 1378. Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease of injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). The factual elements necessary to support a claim under section 1151 based on failure to diagnose or treat a preexisting condition may vary with the facts of each case and the nature of the particular injury and cause alleged by the claimant. As a general matter, however, entitlement to benefits based on such claims would ordinarily require a determination that: (1) VA failed to diagnose and/or treat a preexisting disease or injury; (2) a physician exercising the degree of skill and care ordinarily required of the medical profession reasonably should have diagnosed the condition and rendered treatment; and (3) the veteran suffered disability or death which probably would have been avoided if proper diagnosis and treatment had been rendered. VAOPGCPREC 5-2001 (Feb. 5, 2001); see also Roberson v. Shinseki, 607 F.3d 809, 817 (Fed. Cir. 2010). Moreover, additional disability caused by a veteran's failure to follow properly-given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. 38 C.F.R. § 3.361(c)(3). Third, the proximate cause of the disability, as opposed to a remote contributing cause, must be: (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination; or (2) an event that was not reasonably foreseeable. 38 U.S.C. § 1151(a)(1); 38 C.F.R. § 3.361(d). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination was the proximate cause of a veteran's additional disability or death, it must be shown that the hospital care, medical or surgical treatment, or examination caused the veteran's additional disability or death; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) VA furnished the hospital care, medical or surgical treatment, or examination without the veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(1). Regarding reasonable foreseeability, whether the proximate cause of a veteran's additional disability or death was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have foreseen or disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2); Schertz v. Shinseki, 26 Vet. App. 362, 367-69 (2013). Thus, section 1151 contains two causation elements a veteran's disability must not only be caused by the hospital care or medical treatment he or she received from VA, but also must be proximately caused by the VA's fault or an unforeseen event. 38 U.S.C. § 1151(a)(1). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that compensation under 38 U.S.C. § 1151 for a kidney disorder and a leukocyte disorder are not warranted. The Veteran has contended that he has additional disability as a result of his VA treatment provider over-prescribing certain medications (Allopurinol and Colchicine) for his gout. He has indicated that he was given very high doses of these medications around 2011, which resulted in kidney and leukocyte disorders. See, e.g., April 2012 claim; May 2012 written statement; September 2016 Bd. Hrg. Tr. at 13-21. Historically, the Veteran began VA treatment for gout in the late 1990s. In June 1999, he sought treatment for what was noted as polyarthritis. He reported that he had felt well until one year prior and then began to develop joint pain. He was noted to already be taking Indomethacin. His uric acid was found to be elevated at that time, and he was started on Colchicine for treatment of an acute flare of gout. It was noted that he would be a good candidate for Allopurinol treatment; he began taking that medicine daily during the following month. See VA treatment records from June 1999 and July 1999. Thereafter, the Veteran was treated for gout flare-ups with Colchicine and also took Indocin (Indomethacin), with varying levels of compliance for regular treatment with Allopurinol. See, e.g., VA treatment records from September 1999, May 2000, October 2000, May 2001, October 2001, February 2002, and May 2002. In January 2003, he was restarted on Allopurinol at a dosage of 300 milligrams (mg) a day (qd), and the dosage was increased to 300 mg twice a day (bid) in August 2003. See VA treatment records from January 2003 and August 2003; see also, e.g., VA treatment records from October 2003 (showing an assessment of very bad gouty arthritis disease; Veteran should continue Allopurinol dosage and Indomethacin as needed (prn)) and August 2006 (noting Veteran taking Allopurinol rarely and Colchicine for weekly attacks). The record shows that the Veteran had been on Allopurinol intermittently since 2003, including restarting the medication in August 2007 to January 2008, then restarting with a dosage of 600 mg a day in February 2008 (working up to a target dose of 750 mg a day several months later). He was also prescribed Colchicine to help prevent gout and pseudogout attacks at a dosage of 0.6 mg once or twice a day depending on creatinine levels (noted to be a daily low dose), as well as Prednisone for joint inflammation attacks at that time. See February 2008 VA treatment record. In the May 2008 rheumatology appointment, the Veteran reported that he was not aware of any intolerance or adverse effects from those medications, and he was pleased with the general improvement in his joint pains. In the November 2008 rheumatology appointment, the treatment provider noted that the dose of Allopurinol being given in this case was higher than usually required, but had been demonstrated both this recent time as well as in the past as the dose needed to normalize the Veteran's serum uric acid and should not be stopped save for concern of an ongoing Allopurinol side effect. The physician further noted that the Veteran had been told this information in the past and was again reminded of it. See VA treatment records from May 2008 and November 2008. The Veteran continued these dosages for some time thereafter. See, e.g., September 2010 VA treatment record. In December 2010, the Veteran's Allopurinol was reduced to 600 mg based on a review of his uric acid level, and Colchicine was discontinued following the pharmacy's recommendation to discontinue that medicine if clinically appropriate based on a notation of new medical evidence. See VA treatment records from December 2010 and April 2011. The April 2011 VA treatment record also shows that the Veteran reported that he was unaware of any adverse effects from his Allopurinol. The August 2012 VA examiner also explained that the reason that the Colchicine was likely discontinued (while poorly documented) was that it went from generic to trade around that time and the cost went up significantly. Thus, the examiner explained that many VA pharmacies were asked to review the prescription and make a recommendation for its discontinuation if appropriate. The examiner noted that, in this case, Colchicine was discontinued because the Veteran's uric acid level was well-controlled on the Allopurinol, and the Allopurinol dose was lowered due to low uric acid. Thereafter, VA treatment records show that the Veteran took Indomethacin or Prednisone for gout flares, but he did not take Allopurinol as of November 2011. See, e.g., VA treatment records from August 2012, January 2013, and June 2013. He later agreed to restart Allopurinol several years later due to frequent flares, eventually returning to dosages similar to those from 2008 to 2011. See VA treatment records from February 2015, June 2015, February 2016, and March 2017 (restarted on Allopurinol at 300 mg daily, increased to 600 mg and then 700 mg/800 mg). Kidney In this case, the record shows that the Veteran has chronic kidney disease (CKD) and kidney cysts, and he had these diagnoses during the relevant time period outlined above. For example, he was seen for a VA nephrology consultation in February 2012 for management of CKD which he was noted to have over the last ten years; his creatinine levels had been in a certain range for the past few years. It was also noted that he had hypertension since age 30 that was not well-controlled by his own report, one episode of kidney stones in the 1990s, gout with a history of flares, and a history of cocaine use. The assessment was CKD with differential diagnoses including hypertension nephropathy, acute interstitial nephritis (AIN) from nonsteroidal anti-inflammatory drugs (NSAIDs), or uric acid nephropathy. In 2014, VA nephrology treatment records from ongoing treatment show that the CKD was stage III with an unclear etiology, but that the etiology was likely hypertension. The treatment provider ordered testing to rule out any possible lead exposure, noting that there was no clear history of such exposure. The Veteran's renal function was also noted to have been fairly stable over the past few years. The results of the testing did not show high levels of lead, but the treatment provider explained to the Veteran that his uric acid levels were noted to be high, which could cause gout and is associated with reduced kidney function. In early 2015, the Veteran was noted to have chronic renal failure with a slow loss of kidney function over the past twelve years and intermittent positive tests for cocaine. He was instructed by his treatment provider that cocaine was not good for him because it could raise his blood pressure and damage the kidneys. In mid-2015, he continued to be followed in the renal clinic for CKD and hypertension, noted to be in the setting of gout and cocaine use. He was again advised by his treatment provider at that time to avoid NSAIDs, as well as illicit drugs (cocaine). His renal status remained the same thereafter. See, e.g., VA treatment records from November 2013, March 2014, April 2014, January 2015, July 2015, October 2019 (CKD); see also VA treatment records from February 2012 (renal ultrasound) and January 2013 (urology note) for kidney cysts. The October 2019 VA treatment record shows that the stage III CKD still seemed around baseline. The August 2012 VA examiner reviewed the claims file, including the history of the Veteran's medications up until the discontinuation of Colchicine and Allopurinol, and determined that the Veteran's long-standing hypertension was much more likely the culprit for his CKD, rather than his intermittent use of Indometacin and NSAIDs. In so finding, the examiner noted that a review of the blood pressure documents in the treatment records show variably controlled blood pressures with the trend toward higher blood pressures more recently. He also noted that the Veteran's creatinine level was currently near where it was in 2002 and that Allopurinol and Colchicine are not common or even uncommon causes of CKD. In an April 2017 clarifying medical opinion, the same examiner confirmed his opinion as to hypertension causing the Veteran's kidney problems, as well as his cocaine use. In so finding, he noted that the Veteran's creatinine levels continued to slowly worsen since his last review of the records. He also noted that review of the VA treatment records showed that the staff nephrologist warned the Veteran about the need for better blood pressure control and to abstain from cocaine, as both were affecting his kidneys. In addition, he found that there was no evidence that the Veteran was overmedicated or inappropriately medicated by his providers based on review of the record. Regarding the renal cysts, the examiner determined that they are incidental findings not caused by or related to the Veteran's gout or its treatment, noting that the Veteran's medicines do not cause or aggravate renal cysts. The Board also finds that, although the Veteran has been shown to have kidney disability during the relevant time period, the most probative evidence (including consideration of the lay statements as discussed below) does not establish that any additional disability (to the extent such was actually shown) was a result of the period of VA treatment for which he claims he was over-prescribed Allopurinol and Colchicine for his gout. If the Board finds that there is no "actual causation," it is unnecessary to address the next step of proximate causation (i.e., negligence and reasonable foreseeability). That is, because the evidence of record does not demonstrate additional disability caused by VA treatment, examination, or surgery, the analysis need not advance to the question of proximate cause, including negligence and reasonable foreseeability. Mangham v. Shinseki, 23 Vet. App. 284, 287-88 (2009); Loving v. Nicholson, 19 Vet. App. 96, 99-100 (2005); see also 38 U.S.C. § 1151(a)(1) and 38 C.F.R. § 3.361(d), Anderson v. Principi, 18 Vet. App. 371, 377 (2004) (noting legal distinction between filing a claim for service connection under 38 U.S.C. § 1110 and a claim for compensation under 38 U.S.C. § 1151). The Board has considered the Veteran's statements. Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, the questions of additional disability for purposes of entitlement to section 1151 benefits for the claimed disability falls outside the realm of common knowledge of a lay person. See Kahana and Jandreau, supra. Moreover, even assuming that he is competent to opine on these medical matters, the Board finds that the VA examiner's opinions are more probative, as they were provided by a medical professional with knowledge, training, and expertise and is supported by rationale based on such knowledge. The VA examiner reviewed the claims file and considered the Veteran's reported history and lay statements. Similarly, the Board has considered the articles submitted by the Veteran with his claim. While the Board acknowledges this submission, there is no evidence of record showing that the general statements in this regard apply to the Veteran's specific case. See Sacks v. West, 11 Vet. App. 314, 317 (1998) ("This is not to say that medical article and treatise evidence are irrelevant or unimportant; they can provide important support when combined with an opinion of a medical professional."). Based on the foregoing, the Board finds that the criteria for entitlement to compensation under 38 U.S.C. § 1151 for a kidney disability have not been met, and the weight of the evidence is against the Veteran's claim. As such, the benefit-of-the-doubt rule does not apply, and the claim is denied. Leukocyte In this case, the record shows findings related to the Veteran's leukocyte levels. See, e.g., VA treatment records from January 2013 (nitrite has slight amount of leukocyte esterase), July 2013 (leukocytosis, improving today, likely 2/2 gout), and January 2016. In the April 2017 medical opinion, the VA examiner determined that the Veteran did not have a current leukocyte disorder, but rather he had temporary leukocytosis in the blood that resolved. In so finding, he explained that a significant flare-up of gout can cause a patient to have a temporary leukocytosis in the blood, but that the condition was transient based on white blood cell count laboratory findings, and there was no chronic leukocytosis or white blood cell condition due to the Veteran's gout or its treatment. He also explained that the urine leukocyte esterase findings were not medically significant and that the urinalysis findings reflected that there was also no evidence of a leukocytosis issue of the urine. The VA treatment records support the examiner's findings. For example, VA treatment records for follow-up after 2017 gout flare treatment shows that the treatment provider noted that leukocytosis can be seen in gout flares and that she would also continue to consider other infectious causes. During the following month, another treatment provider noted that the leukocytosis was likely due to some combination of hemoconcentration and recovering stress response, supporting the temporary nature of the condition. See VA treatment records from August 2017 and September 2017. The August 2012/April 2017 VA examiner's determinations, which address the central medical issues in this case, were based on an analysis of the evidence and current medical understanding, and they are therefore entitled to probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (an examination is not rendered inadequate where the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion"); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). In summary, the Board finds that the most probative evidence (including consideration of the lay statements as discussed below) shows that the Veteran does not have a current leukocyte disorder, and he does not have any additional leukocyte disability as a result of the period of VA treatment for which he claims he was over-prescribed Allopurinol and Colchicine for his gout. In the absence of additional disability shown as a threshold issue, there remains no further question as to whether there is causation from the VA treatment. The Board has considered the Veteran's statements. Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, the questions of additional disability for purposes of entitlement to section 1151 benefits for the claimed disabilities falls outside the realm of common knowledge of a lay person. See Kahana and Jandreau, supra. Moreover, even assuming that he is competent to opine on these medical matters, the Board finds that the VA examiner's opinions are more probative, as they were provided by a medical professional with knowledge, training, and expertise and is supported by rationale based on such knowledge. The VA examiner reviewed the claims file and considered the Veteran's reported history and lay statements. Similarly, the Board has considered the articles submitted by the Veteran with his claim. While the Board acknowledges this submission, there is no evidence of record showing that the general statements in this regard apply to the Veteran's specific case. See Sacks v. West, 11 Vet. App. 314, 317 (1998) ("This is not to say that medical article and treatise evidence are irrelevant or unimportant; they can provide important support when combined with an opinion of a medical professional."). Based on the foregoing, the Board finds that the criteria for entitlement to compensation under 38 U.S.C. § 1151 for a leukocyte disability have not been met, and the weight of the evidence is against the Veteran's claim. As such, the benefit-of-the-doubt rule does not apply, and the claims are denied. REASONS FOR REMAND On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran's remaining claim. The Veteran was provided a VA examination in connection with his claim for service connection for a lumbosacral spine disorder in January 2011. The Board requested an additional VA examination to consider whether contemporaneous lumbar spine x-rays were necessary and to provide a more complete etiology opinion. Another VA examiner conducted a new VA examination in May 2017 and also provided a July 2017 clarifying medical opinion. The examiner did address questions related to the diagnosed disorders (lumbosacral strain and spina bifida occulta at S1); however, an additional VA medical opinion is needed because some medical questions remain, including the medical significance, if any, of a more recent CT scan finding not addressed by the examiner, as detailed in the directives below. The case is REMANDED for the following action: The AOJ should refer the Veteran's claims file to a suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of any current lumbosacral spine disorder that may be present. An additional examination of the Veteran should only be performed if deemed necessary by the individual providing the opinion. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records and personnel records, post-service medical records, and statements. The Veteran has essentially contended that in-service symptoms during his first period of service were early manifestations of current lumbosacral spine problems. He has also contended that these current problems are related to his in-service duties, such as shoveling. See, e.g., September 2016 Bd. Hrg. Tr. at 3-6. The Veteran's service treatment records show complaints referable to his joints, including an impression of a lumbosacral strain in July 1973. See, e.g., service treatment records from May 1973, June 1973, July 1973, and December 1973 (including documentation of joint complaints and viral syndrome); see also, e.g., service treatment records from subsequent Reserve service (May 1976 and November 2014 VBMS entries) and VA examination reports from October 1986, April 2002, January 2011, and May 2017 with July 2017 clarifying medical opinion. The 2011 and 2017 VA examiners diagnosed the Veteran with a lumbar/lumbosacral strain and spina bifida occulta at S1, with the 2017 examiner finding that the second diagnosis was congenital in nature and based on findings in a December 2003 x-ray report. An April 2017 VA CT scan of the abdomen and pelvis shows disc space narrowing at L5-S1 (with an impression focused on other medical issues prompting the testing). It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should then address the following: (1) Whether the Veteran's spina bifida occulta is a congenital defect or disease. To assist the examiner, for VA adjudication purposes, "disease" generally refers to a condition considered capable of improving or deteriorating, whereas "defect" generally refers to a condition not considered capable of improving or deteriorating. As an example, VA considers sickle cell anemia as congenital "disease" for VA purposes, whereas refractive error is considered a congenital "defect." (a) If the Veteran's spina bifida occulta is a congenital defect, the examiner should state whether there is evidence of a superimposed disease or injury during service. (b) If the Veteran's spina bifida occulta is a congenital disease, the examiner should state whether the disease preexisted the Veteran's military service. If so, the examiner should state whether there was an increase in the severity during service. If the evidence reflects such an increase, the examiner should indicate whether any increase was due to the natural progression of the disorder or whether it represented a chronic worsening of the underlying pathology. (c) If the Veteran's spina bifida occulta is not congenital and/or did not preexist service, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to his military service, including any symptomatology therein. (2) For each diagnosis identified other than spina bifida occulta, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to the Veteran's military service, including any symptomatology therein. It should be noted that this additional opinion has been requested in light of the April 2017 VA CT scan of the abdomen and pelvis showing disc space narrowing at L5-S1 that was not addressed by the 2017 VA examiner. The current examiner need not address the lumbar/lumbosacral strain diagnosis if he or she determines that this CT scan finding is related to the spina bifida occulta above or a new diagnosis other than lumbar/lumbosacral strain. In providing this opinion, the examiner should discuss medically known or theoretical causes of any currently diagnosed disorder and describe how such a disorder generally presents or develops in most cases, in determining the likelihood that the current disorder is related to in-service events as opposed to some other cause. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Postek, 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.