Citation Nr: 21030440 Decision Date: 05/18/21 Archive Date: 05/18/21 DOCKET NO. 16-32 475 DATE: May 18, 2021 REMANDED 1. Entitlement to service connection for a sleep disorder, to include obstructive sleep apnea (OSA) and sleep disturbance, is remanded. 2. Entitlement to service connection for a lumbar spine (low back) disability, to include as secondary to the service-connected Dercum's disease, is remanded. 3. Entitlement to service connection for a pelvic disability, claimed as pelvic pain, to include as secondary to the service-connected Dercum's disease, is remanded. 4. Entitlement to a bilateral foot disability, claimed as numbness of the feet, to include as secondary to the service-connected Dercum's disease, is remanded. 5. Entitlement to service connection for a bilateral hand disability, claimed as numbness of the hands, to include as secondary to the service-connected Dercum's disease, is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1995 to May 1999. In January 2021, the Veteran provided testimony at a virtual Board hearing before the undersigned Veterans Law Judge (VLJ). 1. Entitlement to service connection for obstructive sleep apnea is remanded. The Veteran contends that service connection for obstructive sleep apnea (OSA) is warranted because it was incurred in or otherwise caused by service, to include as secondary to the service-connected Dercum's disease. During the January 2021 Board hearing, the Veteran testified that while on active duty his ex-wife would tell him that he was snoring and would stop breathing during sleep. Service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. The Board notes that secondary service connection on the basis of aggravation may be granted only when there is an increase in severity of the nonservice-connected disability beyond a medically established baseline due to the service-connected disability. The regulation specifically states that VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established. 38 C.F.R. § 3.310(b). This baseline is to be established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. Id. In May 2016, the Veteran was afforded a VA medical examination and the examiner opined that the Veteran's sleep disturbance, to include OSA, was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected Dercum's disease. He stated that the most important risk factors for OSA are advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities. The examiner noted that the Veteran was overweight with a body mass index (BMI) over 30.78, which he explained is considered moderately obese, and a neck circumference of 1712 inches or more for men which is associated with a higher risk of sleep apnea. He concluded, as per medical literature, enough study was not done yet to show a cause and effect relationship between Dercum's disease / lipomatosis and OSA. In an October 2019 appellant's brief, the Veteran's representative asserted that obesity, while not a disability for compensation purposes, can be a stepping stone to secondary disabilities resulting from the obesity. It was noted that the November 2018 psychiatric examination report included chronic sleep impairment as a manifestation of the Veteran's service-connected psychiatric disability. The Veteran asserts that his service-connected obsessive-compulsive disorder and secondary depressive disorder has caused his obesity, and the obesity, in turn, has resulted in sleep apnea and further impacted his low back disability. The Veteran's representative also argued that the May 2016 examiner failed to address whether aggravation was involved. When VA undertakes to obtain an examination, it must ensure that the examination and opinion therein is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). In review of the opinion provided in May 2016, the Board finds the opinion to be inadequate for adjudication purposes. While the examiner discussed secondary causation, he did not provide an opinion as to aggravation of the Veteran's claimed sleep apnea disability by the service-connected Dercum's disease. The Board emphasizes that obesity cannot qualify as an in-service event to warrant service connection for another disability because it occurs over time. Although service connection is not allowed for obesity on its own, obesity could act as an "intermediate step" to establish service connection for another disability as secondary to an already service-connected disability under certain circumstances. See VAOPGCPREC 01-17 (January 6, 2017). An addendum opinion, with adequate rationale, on whether the Veteran's OSA was aggravated by the service-connected Dercum's disease and/or obsessive compulsive disorder and secondary depressive disorder, and as to what extent, if any, the Veteran's service-connected disabilities contributed to his OSA through the intermediate step of causing his obesity. See VAOPGCPREC 1-2017. Moreover, VA medical records indicate that the Veteran underwent a sleep study in January or February 2016 at Princeton Community Hospital when the Veteran was diagnosed with OSA, and no records from this provider is associated with the claims file. As such, the Veteran should be provided an opportunity to identify any additional outstanding relevant private medical records on remand. An effort must be made to locate and associate any outstanding private medical records with the Veteran's claims file and updated VA medical records should be obtained. 2. Entitlement to service connection for a lumbar spine (low back) disability, to include as secondary to the service-connected Dercum's disease, is remanded. 3. Entitlement to service connection for a pelvic disability, claimed as pelvic pain, to include as secondary to the service-connected Dercum's disease, is remanded. 4. Entitlement to a bilateral foot disability, claimed as numbness of the feet, to include as secondary to the service-connected Dercum's disease, is remanded. 5. Entitlement to service connection for a bilateral hand disability, claimed as numbness of the hands, to include as secondary to the service-connected Dercum's disease, is remanded. The Veteran contends that service connection for a lumbar spine, pelvic, bilateral foot, and bilateral hand disabilities are warranted because they incurred in or otherwise caused by service, to include as secondary to the service-connected Dercum's disease. During the January 2021 Board hearing, the Veteran testified that he experienced "ghost pains" in his pelvis since service discharge. He stated that he can remember waking up and hardly being able to get out of bed, having to move around to loosen up, which had gotten progressively worse. He explained that there were hundreds of lipomas in his back area and when he sought treatment through Dr. Herbst, he was told that the lipomas were attaching to his nerves around his spine, which also lead to the hands and feet. The Veteran's contention is that he had low back and pelvic pain while in service and the numbness in his hands and feet came later, specifically, as the lipomas started to multiply. He believes that the attachment of the lipomas to the respective nerves are the cause of his claimed disabilities. VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). VA will provide a medical examination or obtain a medical opinion if the evidence indicates the existence of a current disability or persistent or recurrent symptoms of a disability that may be associated with an event, injury, or disease in service, and there is insufficient medical evidence of record to decide the claim. 38 U.S.C. § 5103A(d)(2); 38C.F.R. § 3.159(c)(4)(i); McLendon, 20 Vet. App. at 79. When VA undertakes to obtain an examination, it must ensure that the examination and opinion therein is adequate. Barr, 21 Vet. App. 303. The Veteran was afforded a VA examination for his claimed lumbar spine, pelvic, bilateral feet, and bilateral hand disabilities in May 2016. The examiner found that the Veteran's claimed lumbar spine disability was less likely than not (less than 50 percent probability) proximately due to or the result of the service-connected Dercum's disease. He provided the rationale that physical examination of the Veteran's back was normal, and his lumbar spine x-ray revealed degenerative lumbar disc disease, which is more likely a part of generalized degeneration due to age. The examiner documented that he reviewed peer reviewed medical literature and found that there was not enough study done yet to show a cause-and-effect relationship between Dercum's disease/lipomatosis and degenerative disc disease. The examiner also opined that the Veteran's claimed pelvic disability was less likely than not proximately due to or the result of the service-connected Dercum's disease. He explained that there was no pathology detected to render the diagnosis of a hip condition on examination with both hip x-rays being normal and therefore stated that it did not need a medical opinion. The examiner added there was no documented diagnosis of his bilateral hip condition in his problem lists. He documented that he reviewed peer reviewed medical literature and found that there was not enough study done yet to show a cause-and-effect relationship between Dercum's disease/lipomatosis and a bilateral hip condition. Lastly, the examiner opined that the Veteran's claimed numbness and tingling of the four extremities was less likely than not proximately due to or the result of the service-connected Dercum's disease. The examiner found that there was no pathology detected to render the diagnosis of a peripheral nerves condition on examination and thus, it did not need a medical opinion. He noted that there was no documented diagnosis of a peripheral nerves condition in the problem lists. He documented that he reviewed peer reviewed medical literature and found that there was not enough study done yet as to show a cause-and-effect relationship between Dercum's disease/lipomatosis and peripheral nerve disease. In review of the opinions provided in May 2016, the Board finds the opinions to be inadequate for adjudication purposes. While the examiner discussed secondary causation, he did not provide an opinion as to aggravation of the Veteran's claimed disabilities by the service-connected Dercum's disease. El-Amin, 26 Vet. App. at 140. Moreover, the Board is mindful of Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the U.S. Court of Appeals for the Federal Circuit explained that where pain alone results in functional impairment that affects earning capacity, even if there is no identified underlying diagnosis, it can constitute a disability. The Veteran has consistently complained of lumbar spine, pelvic, feet, and hand pain throughout the record. The May 2016 examiner has indicated that a medical opinion was not needed because there was no pathology for the respective disabilities. In light of the Veteran's complaints of pain, the Board finds that it is necessary to address whether the Veteran has any functional impairment of the lumbar spine, pelvic, feet, and hands. Importantly, the VA examiner did not directly discuss the Veteran's contention that the lipomas from his Dercum's disease attached to the respective nerves of his claimed disabilities. Therefore, the Board finds that addendum VA medical opinions are necessary to adjudicate the claimed disabilities above. During the January 2021 Board hearing, the Veteran also testified that he started treatment with a family physician in the early 2000's, Dr. Lohuis, who documented back pain. Piecemeal records from this provider are associated with the claims file, which indicates that potentially relevant records may be outstanding. As such, the Veteran should be provided an opportunity to identify any additional outstanding relevant private medical records on remand. An effort must be made to locate and associate any outstanding private medical records with the Veteran's claims file The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private medical records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, an effort must be made to obtain all outstanding records, to include but are not limited to records from the following medical professionals: January or February 2016 sleep study at Princeton Community Hospital; A family physician, Dr. Nancy Lohuis, since around 2004; Dr. Karen Herbst; Dr. Eric S. Hopkins; and any other private medical professional whose records would be relevant to the issues on appeal. 2. Obtain all outstanding VA treatment records since February 2020 and associate them with the claims file. 3. Return the Veteran's claims file to the May 2016 VA examiner who performed the examination and provided the opinions for the claimed obstructive sleep apnea (OSA), or to a qualified medical professional if the examiner is unavailable, to provide an addendum opinion. If the examiner finds that an in-person examination is necessary, then schedule an examination. If an examination is scheduled, any indicated evaluations, studies, and tests deemed to be necessary by the examiner should be performed. The examiner should be provided a copy of the below facts. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: The Veteran served on active duty from May 1995 to May 1999. The Veteran is service connected for Dercum's disease with iron deficiency and obsessive compulsive disorder and secondary depressive disorder, not otherwise specified. The Veteran is mainly contending that his current OSA was caused by or aggravated by his service-connected Dercum's disease. The Veteran also asserts that his service-connected obsessive-compulsive disorder and secondary depressive disorder has caused his obesity, and the obesity in turn has resulted in sleep apnea and further impacted his back condition. The Veteran has also testified that while on active duty his ex-wife would tell him that he was snoring and would stop breathing during sleep. The Veteran served on active duty from May 1995 to May 1999. A December 1998 Report of Medical History for purposes of separation from service shows the Veteran documented that he was in "good health" and denied that he ever had or had at the time, "been a sleep walker;" "asthma;" "shortness of breath;" "pain or pressure in chest;" "chronic cough," "frequent trouble sleeping;" and "periods of unconsciousness." See VBMS entry with document type, "STR," receipt date 06/22/2009, on pages 73-74. The December 1998 Report of Medical Examination at service discharge reflects a normal clinical evaluation of the "lung and chest," "nose," and "mouth and throat." He weighed 165 lbs. See VBMS entry with document type, "STR," receipt date 06/22/2009, on pages 75-76. A November 2014 VA medical record reflects a review of symptoms for the respiratory system that was positive for dyspnea on exertion and negative for asthma, sleep apnea, cough, and wheezing. The Veteran weighed 183.9 lbs at the time. See VBMS entry with document type, "CAPRI," receipt date 08/20/2018, on pages 665-667. In August 2015 VA medical records, the Veteran reported that he was "still tired a lot." He reported that bupropion had been "well-tolerated" but was not sure if it was "doing much." He noted a number of stressful events and that he had "handled them pretty well, including buying a new home, son starting college, and re-establishing relationship with his daughter after over a year." See VBMS entry with document type, "CAPRI," receipt date 08/27/2018, on pages 522-523. The same record documents the Veteran reporting he had been weaning himself off escitalopram and planned to discontinue use. The Veteran stated that he "wakes up tired, stays tired throughout the day with low energy" and that he even "sometimes falls asleep at work." He reported that he was a "loud snorer" and his wife "sometimes kicks him out of the bed because of [snoring]" and that she says he wakes himself up snoring. The Veteran had not had a sleep study at this point. See VBMS entry with document type, "CAPRI," receipt date 08/27/2018, on pages 522-523. August 2015 VA medical records reflect that the Veteran's weight was 201 lbs with a body mass index (BMI) of 30.6. Id. at page 525. In October 2015 VA medical records, the Veteran reported increased shortness of breath with exertion over the preceding few months. It was noted that the Veteran had put on some weight and had some psychiatric medication switched a few months prior. The Veteran had gotten married in July [2015] and was noticing such severe sleep apnea that his wife was sleeping at night in a separate bed due to snoring. The Veteran had no history of asthma, there no chest pain reported, but the Veteran had daytime fatigue. See VBMS entry with document type, "CAPRI," receipt date 08/27/2018, on page 512. Upon physical examination in October 2015, the Veteran was noted to have gained weight; 209.3 lbs at the time with a BMI of 31.9. Tender fatty tumors scattered over the entire body were also indicated. Id. at page 513. A January 2016 VA medical record documents that a sleep study was performed in January 2016 at Princeton Community Hospital and scanned under the VistA Imaging. The sleep study is not located within this record, but rather the record shows it was uploaded into VistA Imaging. See VBMS entry with document type, "CAPRI," receipt date 08/27/2018, on 459. A May 2016 VA examination report for the Veteran's claimed OSA shows the Veteran reported that the prescribed a Continuous Positive Airway Pressure (CPAP) that had been helping but he still had daytime tiredness. See VBMS entry with document type, "C&P Exam," with "DBQ RESP Sleep Apnea" in the Subject field, receipt date 05/03/2016. The VA examiner opined that the Veteran's sleep disturbance, to include OSA, was less likely than not (less than 50 percent probability) proximately due to or the result of the service-connected Dercum's disease. The examiner noted that the most important risk factors for OSA are advancing age, male gender, obesity, and craniofacial or upper airway soft tissue abnormalities. The examiner documented that the Veteran was overweight with a BMI over 30.78, considered moderately obese, and a neck circumference of 1712 inches or more for men which is associated with a higher risk of sleep apnea. The examiner concluded, as per medical literature, enough study was not done yet to show a cause-and-effect relationship between Dercum's disease / lipomatosis and OSA. See VBMS entry with document type, "C&P Exam," with "DBQ Medical Opinions" in the Subject field, receipt date 05/03/2016, on pages 7-8. In a January 2017 VA medical record, the Veteran stated that he had contacted Princeton Community Hospital and "voiced my continued problems of waking up multiple waking up multiple times throughout the night, feeling as if I cannot exhale as the air is being forced, removing the mask because of my inability to breath out, still feeling fatigued, and my wife stating that I continue to snore even with the mask on." See VBMS entry with document type, "CAPRI," receipt date 08/20/2018, on page 220. In a February 2017 VA pulmonary consultation, the Veteran was seen for not tolerating CPAP. The pulmonologist indicated that after reviewing the diagnostic and titration sleep studies, it looked like the Veteran needed less CPAP pressure if the REM sleep would come earlier. The Veteran was on Selective Serotonin Reuptake Inhibitor (SSRI) and had very prolonged REM latency with inadequate REM. He noted that the Veteran's tiredness might have been related to the absence of deep and REM sleep and SSRI may be responsible for that. See VBMS entry with document type, "CAPRI," receipt date 08/20/2018, on pages 213-215. In September 2017 VA medical records, the Veteran complained, "I'm tired all the time." He reported that he had been having issues with his CPAP, was not sleeping well, and felt tired all the time. He stated that his pulmonologist thinks he is not getting good sleep while he was on escitalopram. See VBMS entry with document type, "CAPRI," receipt date 08/20/2018, on pages 151-152. In a November 2018 Disability Benefits Questionnaire (DBQ) for mental disorders, the examiner noted that the Veteran's unspecified depressive disorder symptoms included low appetite, sleep disruption, fatigue, and concentration issues. See VBMS entry with document type, "C&P Exam," receipt date 11/29/2018, with "DBQ PSYCH Mental disorders" in the subject field, on page 2. A January 2019 VA medical record reflects the Veteran's complaint of stress because he was not getting paid with the government shutdown. It was noted that the Veteran had been stressed in the preceding few weeks because he was not getting paid and had not been able to pay some of his bills. He worried that if the shutdown went on longer, he may have been in trouble and said that it affects his sleep sometimes, and knee pain also continued to affect his sleep most nights. See VBMS entry with document type, "CAPRI," receipt date 08/27/2018, on pages 345-346. Additional records may have been associated with the claims file since January 2021. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions based upon the evidence of record and sound medical principles: a) Is it at least as likely as not (50 percent or greater likelihood) that the Veteran's obstructive sleep apnea (OSA) had its onset during service from May 1995 to May 1999? Please state upon what facts, medical principles, and/or medical literature support the opinion. b) If the answer to a) is negative, is it at least as likely as not (50 percent or greater likelihood) that OSA was caused by the service-connected Dercum's disease with iron deficiency? Please state upon what facts, medical principles, and/or medical literature support the opinion. c) If the answer to b) is negative, is it least as likely as not (50 percent or greater likelihood) that OSA was aggravated by the service-connected Dercum's disease with iron deficiency? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. d) If the examiner finds that the service-connected Dercum's disease with iron deficiency aggravates the Veteran's OSA, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for OSA prior to aggravation. If the examiner is unable to establish a baseline for OSA prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. e) If OSA is not caused or aggravated by the service-connected Dercum's disease, is it at least as likely as not (50 percent or greater likelihood) that OSA was caused by the Veteran's service-connected psychiatric disorder; obsessive compulsive disorder and secondary depressive disorder? Please state upon what facts, medical principles, and/or medical literature support the opinion. The examiner should specifically address the assertion that the Veteran's service-connected psychiatric disorder caused weight gain (obesity) that contributed to the onset of OSA. (i.e. the level of his obesity, if any, that is attributable to his service-connected disabilities). f) If the answer to e) is negative, is it at least as likely as not (50 percent or greater likelihood) that OSA was aggravated by the Veteran's service-connected psychiatric disorder? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. The examiner should specifically address the Veteran's contention that his service-connected psychiatric disorder caused weight gain (obesity) that contributed to the worsening of OSA. (i.e. the level of his obesity, if any, that is attributable to his service-connected disabilities). g) If the examiner finds that the Veteran's service-connected psychiatric disorder, aggravates the Veteran's OSA, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for OSA prior to aggravation. If the examiner is unable to establish a baseline for OSA prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. Please explain your answers by citing to supporting clinical data and/or medical literature, as deemed appropriate. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 4. Return the Veteran's claims file to the May 2016 VA examiner who performed the examinations and provided the opinions for the claimed a) lumbar spine, b) pelvic, c) bilateral foot, and d) bilateral hand disabilities, or to a qualified medical professional if the examiner is unavailable, to provide addendum opinions. If the examiner finds that a physical examination is necessary, then schedule an examination. If an examination is scheduled, any indicated evaluations, studies, and tests deemed to be necessary by the examiner should be performed. The examiner should be provided a copy of the below facts. The Veteran served on active duty from May 1995 to May 1999. The Veteran is service connected for Dercum's disease with iron deficiency. The Veteran is mainly contending that his current a) lumbar spine, b) pelvic, c) bilateral foot, and d) bilateral hand disabilities were caused by or were aggravated by his service-connected Dercum's disease. The Veteran testified at a January 2021 hearing that he could remember while in service in service waking up and hardly being able to get out of bed, having to move around to loosen up, which had gotten progressively worse. See VBMS entry with document type, "Hearing Transcript," receipt date 01/08/2021, on pages 7-8. The Veteran explained that there were hundreds of lipomas in his back area and when he sought treatment through Dr. Herbst, he was told that the lipomas were attaching to his nerves around his spine, which also lead to the hands and feet. See VBMS entry with document type, "Hearing Transcript," receipt date 01/08/2021, on pages 14-15. The Veteran asserts that he had back and pelvic pain while in service and the numbness in his hands and feet came later, when the lipomas started to multiply. He believes that the attachment of the lipomas to the respective nerves are the cause of his claimed disabilities. A December 1998 Report of Medical History for purposes of separation from service shows the Veteran documented that he was in "good health" and denied that he ever had or had at the time, "swollen or painful joints;" "cramps in your legs;" "skin diseases;" "tumor, growth, cyst, cancer;" "arthritis, rheumatism, or bursitis," "bone, joint or other deformity;" "loss of finger or toe;" "painful or 'trick' shoulder or elbow;" "recurrent back pain or any back injury;" "'trick' or locked knee;" "foot trouble;" "nerve injury;" and "plate, pin or rod in any bone." The Veteran indicated that he had "broken bones" and documented that it was during a motor vehicle accident as an adolescent. He also reported that he was last in the hospital in approximately May 1997 for an unknown skin rash. See VBMS entry with document type, "STR," receipt date 06/22/2009, on pages 73-74. The Veteran's December 1998 Report of Medical Examination for purposes of service discharge reflects a normal clinical evaluation of the Veteran's "upper extremities," "feet," "lower extremities," "spine, other musculoskeletal," and "neurologic." See VBMS entry with document type, "STR," receipt date 06/22/2009, on pages 75 76. In August 2006, the Veteran had a small lipoma removed from his right arm that was recently noticed. It was noted that he had no history of previous lipomas. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," receipt date 04/07/2014, with "#4" in the Subject field, on pages 1-2. Medical records reveal that the Veteran was given Decadron to treat his right hip in November 2009 and July 2010. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," receipt date 08/06/2014, on page 2. In April 2012, Dr. Hopkins removed multiple lipomas from the Veteran's left arm, right arm, left thigh, right thigh, abdomen, right shoulder, and back. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," receipt date 04/07/2014, with "#4" in the Subject field, on pages 5-12. In March 2014, the Veteran visited Dr. Herbst. The medical record reflects that the Veteran had 50 lipomas removed, last in 2012 by Dr. Hopkins, who told the Veteran that he had to stop removing the lipomas as there were too many. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," with "#1" in the Subject field, receipt date 04/07/2014, on page 1, generally. The lipomas were described as angiolipomas and noted to have been attaching around nerves. The Veteran's hands and feet stay numb and his right forth finger was completely numb. He reported that he felt water tricking in his fat on his back and has itching in his fat. The pain was reported as an 8/10 that was in his head, eyes, muscles, fat, arms, lipomas, or stomach, back legs, feet, and joints. Id. A family history documented that the Veteran's dad and younger brother have a few lipomas. Id. at page 4. Dr. Herbst provided an assessment of familial multiple lipomatosis, Dercum's disease mixed, capillary hemangioma, and lymphatic disease. She noted that Dercum's disease is a disorder of painful fat tissue and described a nodular type, diffuse type, and mixed type. See VBMS entry with document type, "Medical Treatment Record - Non-Government Facility," with "#1" in the Subject field, receipt date 04/07/2014, on page 6, generally. A November 2014 hematologic and lymphatic conditions Disability Benefits Questionnaire (DBQ) includes a diagnosis of neurofibromatosis/multiple lipomatosis. The examiner found that the Veteran's condition impacted his ability to work with reports of painful mass lesion all over his body that he is on gabapentin and Lyrica for. The examiner found that his condition had a functional impaction to his physical and sedentary employment. See VBMS entry with document type, "C&P Exam," receipt date 11/19/2014. A February 2015 skin diseases DBQ documents neurofibromatosis - generalized firm and mildly tender multiple tumor-like feeling with different size and shape under the skin. The areas covered were whole back, buttock, chest wall, anterior abdominal wall, groin area, both arms, and forearm area. See VBMS entry with document type, "C&P Exam," receipt date 02/12/2015. An August 2015 VA medical record shows the Veteran reported that he continued to deal with pain associated with his lipomatosis dolorosum, and said he also had a lot of numbness in his left hand that may be associated with it that caused him a good bit of discomfort. See VBMS entry with document type, "CAPRI," receipt date 04/02/2016, on page 5-6. A May 2016 VA examination report for hip and thigh conditions shows the Veteran reported that he had lumbar back pain and both hip joints including since 2014 and that it had been getting worse. The examiner found that the Veteran did not have a current diagnosis of the bilateral hip (pelvis). See VBMS entry with document type, "C&P Exam," with "DBQ MUSC Hip & Thigh" in the Subject field, receipt date 05/03/2016. A May 2016 VA examination report for peripheral nerves conditions shows the Veteran reported numbness and tingling of both hands since 2014 and denied tingling and numbness of the legs and feet. The examiner found that there was no pathology detected to render the diagnosis of a peripheral nerves condition on examination (bilateral hands and feet). See VBMS entry with document type, "C&P Exam," with "DBQ NEURO Peripheral Nerves" in the Subject field, receipt date 05/03/2016. A May 2016 VA examination report for the back (thoracolumbar spine) condition shows the Veteran reported that he had lumbar back pain and both hip joints including since 2014 and that it had been getting worse. A diagnosis of degenerative lumbar disc disease was provided. See VBMS entry with document type, "C&P Exam," with "DBQ MUSC Back" in the Subject field, receipt date 05/03/2016. Of record are the medical opinions provided by the May 2016 VA examiner, discussed above, for the respective claimed disabilities. See VBMS entry with document type, "C&P Exam," with "DBQ Medical Opinions" in the Subject field, receipt date 05/03/2016, on pages 7-8. Additional records may have been associated with the claims file since January 2021. The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions based upon the evidence of record and sound medical principles: Lumbar spine: a) Is it at least as likely as not (50 percent or greater likelihood) that the Veteran has a current lumbar spine disability or any functional impairment due to low back pain had its onset in service from May 1995 to May 1999? b) If the answer to a) is negative, is it at least as likely as not (50 percent or greater likelihood) that the Veteran's lumbar spine disability (or functional impairment due to low back pain) is caused by the service-connected Dercum's disease with iron deficiency? Please state upon what facts, medical principles, and/or medical literature support the opinion. c) If the answer to b) is negative, is it at least as likely as not (50 percent or greater likelihood) that the lumbar spine disability (or functional impairment due to low back pain) is aggravated by the service-connected Dercum's disease with iron deficiency? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. d) If the examiner finds that the service-connected Dercum's disease with iron deficiency aggravates the Veteran's lumbar spine disability (or functional impairment due to low back pain), the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the lumbar spine disability (or functional impairment due to low back pain) prior to aggravation. If the examiner is unable to establish a baseline for the lumbar spine prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to address the Veteran's contention that his Dercum's disease and associated lipomas cause and/or aggravate the pain through attachment of the nerves. Please consider and discuss the relevant medical records, including but not limited to from Dr. Herbst (locations above). Bilateral hip / pelvic: a) Does the Veteran have a current bilateral hip or pelvic disability or any functional impairment due to hip/pelvic pain? b) For each bilateral hip or pelvic disability (or functional impairment due to hip/pelvic pain) offered, the examiner is asked to address whether it is at least as likely as not (50 percent probability or more) that such disability had its onset in service from May 1995 to May 1999? Please state upon what facts, medical principles, and/or medical literature support the opinion. c) If the answer to b) is negative, is it at least as likely as not (50 percent or greater likelihood) that the Veteran's bilateral hip or pelvic disability (or functional impairment due to hip/pelvic pain) is caused by the service-connected Dercum's disease with iron deficiency? Please state upon what facts, medical principles, and/or medical literature support the opinion. d) If the answer to c) is negative, is it at least as likely as not (50 percent or greater likelihood) that the bilateral hip or pelvic disability (or functional impairment due to hip/pelvic pain) is aggravated by the service-connected Dercum's disease with iron deficiency? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. e) If the examiner finds that the service-connected Dercum's disease with iron deficiency aggravates the Veteran's bilateral hip or pelvic disability (or functional impairment due to hip/pelvic pain), the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the bilateral hip or pelvic disability (or functional impairment due to hip/pelvic pain) prior to aggravation. If the examiner is unable to establish a baseline for the hip/pelvis prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to address the Veteran's contention that his Dercum's disease and associated lipomas cause and/or aggravate the pain (through attachment of the nerves). Please consider and discuss the relevant medical records, including but not limited to from Dr. Herbst (locations above). Bilateral foot: a) Does the Veteran have a current bilateral foot disability or any functional impairment due to foot pain? b) For each bilateral foot disability (or functional impairment due to foot pain) offered, the examiner is asked to address whether it is at least as likely as not (50 percent probability or more) that such disability is caused by the service-connected Dercum's disease with iron deficiency? Please state upon what facts, medical principles, and/or medical literature support the opinion. c) If the answer to b) is negative, is it at least as likely as not (50 percent or greater likelihood) that a bilateral foot disability (or functional impairment due to foot pain) is aggravated by the service-connected Dercum's disease with iron deficiency? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. d) If the examiner finds that the service-connected Dercum's disease with iron deficiency aggravates the Veteran's bilateral foot disability (or functional impairment due to foot pain), the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the bilateral foot disability (or functional impairment due to foot pain) prior to aggravation. If the examiner is unable to establish a baseline for the bilateral foot prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to address the Veteran's contention that his Dercum's disease and associated lipomas cause and/or aggravate the pain (through attachment of the nerves). Please consider and discuss the relevant medical records, including but not limited to from Dr. Herbst (locations above). Bilateral hand: a) Does the Veteran have a current bilateral hand disability or any functional impairment due to hand pain? b) For each bilateral hand disability (or functional impairment due to hand pain) offered, the examiner is asked to address whether it is at least as likely as not (50 percent probability or more) that such disability is caused by the service-connected Dercum's disease with iron deficiency? Please state upon what facts, medical principles, and/or medical literature support the opinion. c) If the answer to b) is negative, is it at least as likely as not (50 percent or greater likelihood) that a bilateral hand disability or any functional impairment due to hand pain is aggravated by the service-connected Dercum's disease with iron deficiency? Aggravation is different from causation in that it did not cause the disability but rather caused an increase in severity that is not due to the natural progress of the disability. Please state upon what facts, medical principles, and/or medical literature support the opinion. d) If the examiner finds that the service-connected Dercum's disease with iron deficiency aggravates the Veteran's bilateral hand disability (or any functional impairment due to hand pain), the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the bilateral hand disability (or functional impairment due to hand pain) prior to aggravation. If the examiner is unable to establish a baseline for the bilateral hand prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. The examiner is asked to address the Veteran's contention that his Dercum's disease and associated lipomas cause and/or aggravate the pain (through attachment of the nerves). Please consider and discuss the relevant medical records, including but not limited to from Dr. Herbst (locations above). Please explain your answers by citing to supporting clinical data and/or medical literature, as deemed appropriate. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. After all available evidence has been associated with the record, review the evidence and determine if further development is warranted. The AOJ should take any additional development as deemed necessary. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Cheng, 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.