Citation Nr: 21040487 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 16-09 097 DATE: July 3, 2021 ORDER The claim of entitlement to a compensable evaluation for residuals of lymphoid infiltrate, non-malignant pelvic soft tissue mass (hereinafter residuals of lymphoid infiltrate) is denied. The claim of entitlement to service connection for sleep apnea syndrome (hereinafter OSA) is denied. The claim of entitlement to service connection for Gulf War Syndrome, manifested by conditions including respiratory issues, joint and muscle pain, and sleep disturbances (hereinafter GWS), to include as due to an undiagnosed illness or medically unexplained chronic multi-symptom illness (MUCMI) as a result of Persian Gulf War Service is denied. REMANDED The claim of entitlement to service connection for chronic kidney disease (CKD), to include as secondary to service-connected disabilities is remanded. FINDINGS OF FACT 1. During the appeal period the Veteran's residuals of lymphoid infiltrate did not manifest as any attacks of colic, with no infections and no catheter drainage required. Additionally, the Veteran had no recurrent stone formation requiring any diet therapy, drug therapy, and no invasive or non-invasive procedures. 2. The Veteran's OSA did not manifest during active service, within one year of his separation from active service and is not otherwise related to his active duty service. 3. The Veteran does not have GWS, to include as due to an undiagnosed illness, nor a MUCMI that manifested during, or as a result of, active military service. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to a compensable evaluation for residuals of lymphoid infiltrate have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.115(b), 4.115(a) Diagnostic Codes (DCs) 7509, 7511 (2019). 2. The criteria to establish entitlement to service connection for OSA have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 3. The criteria to establish entitlement to service connection for GWS to include an undiagnosed illness or a MUCMI as a result of Persian Gulf War Service, manifested by symptoms including respiratory issues, joint and muscle pain, and sleep disturbances have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R.§§ 3.102, 3.303, 3.304, 3.317 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Army from July 1982 to July 1985 and from March 1986 to February 1994. Among other commendations, the Veteran was awarded the Air Assault Badge, Overseas Ribbon, Southwest Asia Service Medal with one Bronze Service Star, and a Saudi Kuwait Liberation Medal. These matters are before the Board of Veteran's Appeals (Board) from the November 2012 and the July 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) that denied an increased rating for the Veteran's residuals of lymphoid infiltrate, and service connection for OSA, GWS, and CKD. The Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO in Atlanta, Georgia in October 2018. A written transcript of that hearing has been prepared and associated with the evidence of record. The Board in April 2019 issued a decision that dismissed the Veteran's claim for erectile dysfunction and reopened the Veteran's claims for service connection for GWS and CKD, to include as secondary to residuals of lymphoid infiltrate. The Board then remanded the Veteran's claims for new VA examinations and medical opinions on the issues of an increased rating for residuals of lymphoid infiltrate, for GWS, for service connection for CKD to include as secondary to residuals of lymphoid infiltrate, and for service connection for OSA. The Board also notes that the Veteran, through counsel, requested a 90-day extension in December 2020 to submit new evidence. The Board granted this extension and has provided the Veteran in excess of 90 days to submit new evidence to support his claims, as of the date of this opinion no new evidence has been submitted. Entitlement to a compensable evaluation for residuals of lymphoid infiltrate The Veteran contends that he is entitled to a compensable evaluation for residuals of lymphoid infiltrate. The Veteran specifically contends that his symptoms of hernia, gastroesophageal reflux disease (GERD), gastric condition, constipation, and kidney issues are due to his residuals of lymphoid infiltrate. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate DCs. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When there is a question between two evaluations, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In accordance with 38 C.F.R. §§ 4.1, 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability. Each disability is viewed in relation to its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). The Board notes that where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. 38 C.F.R. §§ 4.1, 4.2; see also Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. Section 4.14 does not preclude the assignment of separate evaluations for separate and distinct symptomatology where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping, such as pyramiding, with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). VA must consider all favorable lay evidence of record. 38 U.S.C. § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all of the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). When all the evidence is assembled, if there is a balance between positive and negative competent evidence then the issues shall be resolved in favor of the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran's residuals of lymphoid infiltrate are governed by 38 C.F.R. § 4.115 (b) DC 7511 which rates ureter stricture. The rating indicates that the disability is to be rated as hydronephrosis, except for recurrent stone formation requiring one or more of the following: 1) diet therapy, 2) drug therapy, 3) invasive or non-invasive procedures more than two times per year rated at 30 percent. Hydronephrosis is governed by 38 C.F.R. § 4.115 (b) DC 7509 and a 10 percent disability rating requires only an occasional attack of colic, not infected and not requiring catheter drainage. A 20 percent disability rating requires frequent attacks of colic, requiring catheter drainage. The maximum 30 percent disability rating requires frequent attacks of colic with infection (pyonephrosis) with impaired kidney function. Id. The DC also indicates that a finding of severe hydronephrosis is to be rated as renal dysfunction. Renal dysfunction is governed by 38 C.F.R. § 4.115 (a) which indicates a 0 percent disability rating requires albumin and casts with history of acute nephritis; or hypertension non-compensable under DC 7101. A 30 percent disability rating requires albumin constant or recurring with hyaline and granular casts or red blood cells; or transient or slight edema or hypertension at least 10 percent disabling under DC 7101. A 60 percent disability rating requires constant albuminuria with some edema; or definite decrease in kidney function; or hypertension at least 40 percent disabling under DC 7101. An 80 percent disability rating requires persistent edema and albuminuria with blood urea nitrogen (BUN) 40 to 80 mg percent; or creatinine 4 to 8 mg percent; or generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. The maximum rating of a 100 percent disability rating requires regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or BUN more than 80 mg percent; or creatinine more than 8 mg percent; or markedly decreased function of kidney or other organ systems, especially cardiovascular. Id. The Veteran is currently rated at a non-compensable rating for his residuals of lymphoid infiltrate and as indicated below the Board finds that the Veteran is not entitled to a compensable rating. The Veteran received a VA examination for Urinary Tract, Bladder and Urethra Conditions in September 2012 that noted his residuals of lymphoid infiltrate and pelvis soft tissue mass from 1995. The Veteran described the current symptoms of chronic pelvic pain. The examiner found no voiding dysfunction, no urolithiasis, no bladder or urethral infections, no bladder or urethral injury, stricture, or fistula. The examiner further noted that the Veteran had a benign neoplasm that was undergoing watchful waiting treatment but found no residual conditions or complications due to the neoplasm with no functional impact. The Board finds the VA examination to be competent, credible, with significant probative weight. The Veteran received a VA examination in June 2013 for hematologic and lymphatic conditions which noted a diagnosis of anemia. The examiner found that the Veteran's diagnostic testing was most likely consistent with borderline anemia due to renal insufficiency. The examiner indicated that the Veteran was undergoing watchful waiting treatment without any complications or residuals. The examiner also noted no recurring infections and no functional impact. The Board finds the VA examination to be competent, credible, with significant probative weight. Pursuant to the April 2019 Board remand the Veteran received a medical opinion on the residuals of his lymphoid infiltrate in December 2019. The examiner indicated that the Veteran had no residuals from his lymphoid infiltrate. The examiner explained that the lymphoproliferative condition was resolved and no longer present, with regular follow up examinations and diagnostic testing of his chest, abdomen, and pelvis with no evidence of recurrence. The examiner also found that the claimed conditions of hernia, gastrointestinal reflux, a gastric condition, and constipation were not recognized residuals of lymphoproliferative disorder. The examiner noted that the Veteran had no current evidence of inguinal hernia and no ventral hernia from his previous abdominal surgery. The Veteran's gastroesophageal reflux disease (GERD) was noted as not being a residual of the lymphoid infiltrate as a breast and pelvic mass and no other organs such as the stomach or esophagus were involved and no gastric disease was noted in the Veteran's service treatment records. The examiner additionally noted that GERD is due to stomach acid refluxing into the lower esophagus due to sphincter relaxation and muscle weakness. The examiner indicated that constipation has many causes and there was no medical evidence that the Veteran's claim of constipation was a result of the lymphoproliferative disorder. The Veteran's regular follow ups were also noted as showing no gastrointestinal abnormalities due to a recurrence and the examiner documented that diagnostic testing of the abdomen and pelvis in 2009 were negative for abnormalities. The Board finds the VA medical opinion to be competent and credible, with significant probative weight. The Veteran received a VA examination for hernias in September 2020 that noted a supraumbilical hernia from April 2016. The Veteran was noted as stating that he got a ventral hernia about 2 months after his groin mass removal surgery with described symptoms of gas and cramps in his abdomen with exercise. The examiner noted that a supraumbilical hernia is a specific type of epigastric hernia rather than a type of umbilical hernia. The examiner found no objective evidence of a ventral hernia and found no current diagnosis was appropriate of a ventral hernia. The Board finds that the VA examination is competent, credible, and with significant probative weight. The Board finds that the Veteran's VA treatment records showed no medical evidence of a connection to any of the Veteran's claimed symptoms as being due to residuals of lymphoid infiltrate. The Board finds the Veteran's VA treatment records to be competent, credible, and with significant probative weight. The Veteran in October 2018 testified at a hearing where he indicated that he continued to have residuals of lymphoid infiltrate. The Veteran specifically indicated that he had damage to his kidneys which prevents his ability to take pain medication, that he had mild pain, and acid reflux. The Veteran indicated that he had no issues with a hernia and no current hernia condition and his uncontrollable gas had subsided in the last 5 years (approximately 2013). The Board finds that the Veteran's testimony is competent, credible, and with significant weight as such as he is able to indicate his actual experiences and symptoms. The Board recognizes that the Veteran believes his residuals of lymphoid infiltrate caused damage to his kidneys. However, the Board finds that the record does not reflect that the Veteran possesses the required expertise to provide a medical diagnosis or an opinion as to the etiology (origin) of the claimed condition. 38 C.F.R. § 3.159(a)(2). As to the Veteran's lay statements intending to reflect a diagnosis or etiology, they are given limited weight in comparison to the VA examination findings in that regard. The issue of the Veteran's claimed damage to his kidneys and CKD are addressed in the remand section below. The Veteran's residuals of lymphoid infiltrate under DC 7511 are not indicated to be rated under hydronephrosis as the Veteran has no recurrent stone formation requiring one or more of the following: diet therapy, drug therapy, or invasive or non-invasive procedures more than two times per year. As the Veteran has no recurrent stone formation and no required therapies or invasive or non-invasive procedures the Board must look to DC 7509 as directed. Under DC 7509, hydronephrosis, the Veteran is not entitled to an increased rating of a 10 percent disability rating which requires only an occasional attack of colic, not infected and not requiring catheter drainage. As such the Veteran's residuals of lymphoid infiltrate also do not meet the requirements of a 20 percent disability rating which requires frequent attacks of colic which require catheter drainage. Additionally, the Board finds that the Veteran's residuals of lymphoid infiltrate do not rate as severe and need not consider his disability under 38 C.F.R. § 4.115 (a) which governs renal dysfunction. In this case, the Veteran's lay assertions are outweighed by competent and credible medical evidence which evaluated the true extent of his residuals of lymphoid infiltrate. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's condition. For these reasons, greater evidentiary weight is placed on the examination findings regarding the type and degree of impairment. While the Board is sympathetic to the Veteran's report of symptoms, the medical evidence does not support a higher evaluation for residuals of lymphoid infiltrate at any point during the appeal period. The Board also finds that a staged rating is not appropriate in this case. The Board acknowledges that the Veteran has argued that additional DCs be considered when rating his residuals of lymphoid infiltrate. The Veteran argues that his residuals of lymphoid infiltrate be rated under 38 C.F.R. § 4.114, which rate disabilities of the digestive system - he argues that hypertrophic gastritis identified by gastroscope governed by DC 7307, inguinal hernia governed by DC 7338, and hiatal hernia governed by DC 7346 should be considered by the Board. See October 2018 Hearing Transcript. While the Board acknowledges the Veteran's competence to describe the current severity of his symptoms, lay persons are not competent to consider complex medical questions to include assessments of the nature and severity of the symptoms for purposes of establishing an increased rating claim or render a complex medical opinion or diagnosis in the absence of proof of relevant training and expertise. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). Additionally, the Veteran does not have a current diagnosis of an inguinal hernia, a hiatal hernia, nor has he been diagnosed with hypertrophic gastritis by gastroscope. As such these DCs are not applicable to the Veteran's residuals of lymphoid infiltrate. When the preponderance of the evidence weighs against the claims of the Veteran the claim will be denied on its merits. In this case the preponderance of the evidence is against the claims of the Veteran, therefore the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the Veteran's claim for a compensable disability rating for residuals of lymphoid infiltrate is denied. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). VA must consider all favorable lay evidence of record. 38 U.S.C. § 5107. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21. Vet. App. 303 (2007). The Secretary shall consider all information and lay and medical evidence of record in a case and make appropriate determinations as to competence, credibility, and weight. 38 U.S.C. § 5107; 38 C.F.R. § 3.303; Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience, if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. When there is an approximate balance between positive and negative evidence, equipoise, the benefit of the doubt doctrine must apply in favor of the Veteran. But when the preponderance of the evidence weighs against the claims of the Veteran the claim will be denied on its merits, and when the preponderance of the evidence weighs for the claims of the Veteran the claim will be granted on its merits. In those cases, the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for OSA The Veteran contends that he is entitled to service connection for OSA. The Veteran has a current diagnosis of obstructive sleep apnea (OSA), as indicated in a 2006 sleep study. Therefore, the first element of service connection has been met, and the question for the Board is whether the Veteran's current OSA began during his active service or is otherwise etiologically related to his active service. The Veteran's service treatment records are silent as to any issues with sleep disturbance, fatigue, snoring, or daytime sleepiness. However, the Veteran testified in an October 2018 hearing that he would wake in the middle of the night and have broken sleep regularly but never went to a doctor and had no medical knowledge of OSA. His wife testified that he snored loudly and it seemed he would stop breathing for a few minutes during sleep in 1993, which she indicated scared her. A lay witness is competent to report that which may be perceived through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds that the Veteran and his wife's testimony are competent, credible, and with probative weight as to what they experienced. However, the Board finds that the Veteran and his spouse are not considered competent to diagnose OSA or to attribute any sleep disturbances to OSA, as doing so requires medical knowledge and expertise the Veteran and his spouse have not been shown to possess. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board cannot accept their statements as probative evidence linking the current OSA to the Veteran's active service, and the Board must instead turn to the competent evidence of record to determine whether such a link exists. The Veteran was provided a VA examination in December 2019 for OSA, which noted his diagnosis of OSA in 2006 from private sleep study, and additional diagnoses of OSA in January 2012 and in December 2019. The Veteran reported the onset in September 1992 after returning from the Persian Gulf with symptoms of loud snoring, restless sleep, recurrent wakening, morning headaches, forgetfulness, irritability, sleepiness, and lack of energy throughout the day. The Veteran reported his current symptoms in addition to the above as memory loss, mood swings, elevated blood pressure, decreased libido, depression, and asthma. The impact of the condition was noted as poor concentration and performance, constant fatigue during the day, irritated easily, and sleeping in a separate room, and anxiety. The Veteran's use of a continuous positive airway pressure (CPAP) machine was noted, and daytime fatigue was noted as being inadequately controlled. The examiner indicated the functional impact of the Veteran's OSA noted that he should not drive if tired, sleepy, nor operate heavy machinery, and should not climb heights or perform high attention requiring tasks when sleepy, sleep deprived, or if the OSA is untreated. In the VA medical opinion provided in June 2020 the examiner found that the Veteran had complained of trouble sleeping related to physical pain, the examiner explained that trouble sleeping was different from actual OSA when respiratory dysfunction is involved in OSA. The examiner then noted accepted factors that contribute to the development of OSA such as anatomic abnormalities, age, and gender. The examiner found that in 2006, when the Veteran was diagnosed with OSA, he was noted to have a BMI that placed him in the overweight-obese category. The examiner went on to explain that obesity was the number one risk factor in developing OSA and found that the Veteran's OSA was less likely due to or caused by sleep issues or exposures during his active duty service. The Board finds the VA examination to be competent, credible, with significant probative weight. The Board notes that after reviewing the Veteran's VA treatment records that they contain indications of continuing treatment for OSA but no opinions as to whether the Veteran's OSA is due to or the result of his active duty service. As such the Board finds the VA treatment records are competent, credible, but with limited probative weight. The Veteran and his wife testified at a hearing in October 2018 that he would wake up often in the middle of the night and not know why he was not sleeping and that his wife told him he stopped breathing in his sleep. The Veteran's wife indicated that the Veteran would snore and then stop or did not hear anything for a few minutes, seeming that he stopped breathing for a few minutes. The Board finds that the Veteran's and his wife's testimony are with some probative weight as noted above. The Veteran believes his OSA is related to his active duty service but is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the competent, probative medical evidence of record denying an etiological relationship. When considering whether or not to grant a claim for service connection, the Board may take into consideration the passage of a lengthy period of time in which the Veteran did not complain of the disorder at issue. See Maxson v. West, 12 Vet. App. 453, 459 of (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Forshey v. West, 12 Vet. App. 71, 74 (1998), aff'd sub nom. Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (the definition of evidence encompasses "negative evidence" which tends to disprove the existence of an alleged fact, i.e., the lack of evidence is itself evidence). The Board also notes that the Veteran was not diagnosed with OSA until 2006, approximately 12 years after the Veteran separated from service. In this particular case, the lack of treatment for this condition for such an extended period of time is evidence to be worthy of consideration. See Horn v. Shinseki, 25 Vet. App. 231, 239 (2012). In summary, there is no competent medical nor probative medical evidence of record showing that the Veteran's OSA had its onset during his active service or is otherwise etiologically related to his active service. Rather, the probative evidence of record indicates that it would be purely speculative to use the statements to diagnose the Veteran's described symptoms by the Veteran and his wife as OSA or otherwise attribute the current OSA to the Veteran's active service. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim that his OSA had its onset during active service or is otherwise etiologically related to his active service. As such, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. Therefore, the Veteran's claim for service connection for OSA is not warranted. Entitlement to service connection for GWS, to include as due to an undiagnosed illness or MUCMI as a result of Persian Gulf War service The Veteran contends that he is entitled to service connection for GWS to include as due to an undiagnosed illness or MUCMI as manifested by symptoms including respiratory issues, joint and muscle pain, and sleep disturbances as a result of his Persian Gulf War service. Under 38 U.S.C. § 1117 (a)(1) (2012), compensation is warranted for a Persian Gulf War Veteran who exhibits objective indications of a "qualifying chronic disability" that became manifest during service on active duty in the Armed Forces in the Southwest Asia (SWA) Theater of operations during the Persian Gulf War, or to a degree of 10 percent during the presumptive period prescribed by the Secretary. Effective October 16, 2012, VA extended the presumptive period in 38 C.F.R. § 3.317 (a)(1)(i) through December 31, 2016 (for qualifying chronic disabilities that become manifest to a degree of 10 percent or more after active duty in the SWA Theater of operations). See 77 Fed. Reg. 63225 (2012). Furthermore, the chronic disability must not be attributed to any known clinical disease by history, physical examination, or laboratory tests. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317 (a), (b). Because the Veteran served in SWA during his active service, he is a Persian Gulf Veteran within the meaning of the applicable statute and regulation. The Board notes that Congress revised 38 U.S.C. § 1117, effective March 1, 2002. In the revised statute, the term "chronic disability" was changed to "qualifying chronic disability," and the definition of "qualifying chronic disability" was expanded to include (a) undiagnosed illness, (b) a medically unexplained chronic multi-symptom illness (MUCMI) that is defined by a cluster of signs or symptoms, or (c) any diagnosed illness that the Secretary determines, in regulations, warrants a presumption of service connection. Effective June 10, 2003, VA promulgated revised regulations to, in part, implement these statutory changes. See 38 C.F.R. § 3.317 (a)(2). "Objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4). Signs or symptoms which may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) fatigue, (2) unexplained rashes or other dermatological signs or symptoms, (3) headache, (4) muscle pain, (5) joint pain, (6) neurological signs and symptoms, (7) neuropsychological signs or symptoms, (8) signs or symptoms involving the upper or lower respiratory system, (9) sleep disturbances, (10) gastrointestinal signs or symptoms, (11) cardiovascular signs or symptoms, (12) abnormal weight loss, and (13) menstrual disorders. 38 C.F.R. § 3.317 (b). Lay evidence is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition is capable of lay observation and may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature." Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue."). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that he is entitled to service connection for GWS, to include as due to an undiagnosed illness, and/or a MUCMI. Specifically, the Veteran contends that the symptoms of respiratory issues, joint and muscle pain, and sleep disturbances are an undiagnosed illness, MUCMI, or GWS. Service treatment records contained complaints of sore throats, upper respiratory infection, back pain, and knee pain. In the entrance examination of February 1982 there were no indicated issues and the March 1986 entrance examination indicated fair health. The Veteran's separation examination of June 1985 noted no issues of respiratory issues, joint and muscle pain, or sleep disturbances. The periodic examination of January 1991 noted no respiratory issues, joint and muscle pain, or sleep disturbances complaints, treatment, or diagnoses. The Veteran waived his separation examination in November 1993. Specifically, the Veteran was treated for sore throats and an upper respiratory infection in 1983 and 1988. The Veteran was also treated for back, leg, and knee pain in 1986, 1987, and 1989. The Veteran's VA and private treatment records include treatment for joint and muscle issues, respiratory issues, and sleep issues as indicated below. JOINT AND MUSCLE ISSUES The Veteran's medical records in January 2009 indicated a right knee arthroscopy with partial medial meniscectomy and chondroplasty. A May 2009 x-ray of the Veteran's right knee osteoarthritis and June 2009 magnetic resonance imaging (MRI) noted the tear of medial meniscus and lateral meniscus. A doctor letter submitted in July 2009 found the Veteran had no injury to his knee when his symptoms first started and considered whether it was more "the wear or the tear," that was causing the issue. In July 2009 the Veteran sought help to lose weight to lessen strain on his joints. In January 2012 the Veteran's low back pain and right hip pain were noted with symptoms bothering him for many years and noted abnormal findings for the Veteran's back with degenerative joint disease (DJD) and disc wedging in his lumbar. In September 2015 the Veteran was diagnosed with intervertebral disc syndrome (IVDS), spondylosis, and radiculopathy. Also noted in August 2013 the Veteran's left heel pain was found to be an inferior calcaneal spur. In January 2017 it was noted that the Veteran's left knee had a meniscal tear from an MRI that also showed medial and patellofemoral articular cartilage abnormalities. An April 2016 computed tomography (CT) showed the Veteran had mild degenerative joint disease of the sacroiliac joint with mild degenerative facet arthropathy in his L4-5 and L5-S1. In June 2018 the Veteran described his knee pain going back 25 to 30 years, that he experienced back pain after pushing a vehicle out of the mud in service, and a left knee issue beginning 2016-2017 without specific injury, but noted that his back and shoulder pain had improved. The Veteran also indicated that his right knee pain started 25 to 30 years ago and that despite surgery his right knee pain returned. The Veteran's left shoulder pain and arthritis were noted, and his chronic lumbar spondylosis and mild central spinal canal narrowing were documented. In April 2019 the Veteran's hip joints were diagnosed with bilateral bursitis of trochanteric bursa. The Veteran's joint pain was noted as early as 2003, in his medical records, 9 years after his separation from service. The Veteran's VA and private treatment records as to his joint and muscle issues are competent, credible, and with significant probative weight. RESPIRATORY ISSUES Private treatment records indicated possible diagnoses of chronic sinusitis, atrophied nasopharynx, and adenoid hypertrophy in July 1995. The Veteran submitted a doctor note from July 1995 that described the Veteran reporting problems with his abdomen, nasopharyngitis symptoms such as sore throats, recurrent sinus infections, and bronchitis. The doctor indicated that there were severe purulent nasopharyngitis present in granular formation which extended down into the larynx area suspicious for chronic, recurrent nasopharyngitis (common cold). The doctor indicated a possible etiology of AIDS, mono and/or chronic adenoiditis secondary to prolonged exposure to dryness. The records are a paragraph of typed text and a bill for services indicating a nasal endoscopy, x-rays, and partial turbinectomy and a list of diagnoses but no further treatment records were provided. These records also provide no indication of treatment or connection to the Veteran's military service. The Board finds the doctor note and bill to be competent, but without significant probative weight as the record is one page of private treatment and a bill that provide no connection between the Veteran's SWA service and his respiratory issues. Additionally, the doctor only indicated what the Veteran reported. In a June 2012 doctor note it was indicated that the Veteran was initially diagnosed with asthma 1 to 5 years ago. In July 2012 the Veteran was treated for upper respiratory drainage, upper airway cough syndrome, chronic sinusitis, allergic rhinitis, and although denied symptoms that the Veteran needed to consider reflux as a possible cause. The Veteran's private treatment records in September 2015 received an updated respiratory assessment that noted diagnoses of extrinsic asthma unspecified, cough, allergic rhinitis with an unspecified cause, chronic rhinitis, unspecified sinusitis, and asthma unspecified. An April 2016 respiratory assessment found the Veteran had allergic rhinitis due to allergens of dust, dog, tress, grass, and weeds and chronic sinusitis unspecified. An additional respiratory assessment in April 2018 noted allergic rhinitis due to pollen, asthma, and chronic sinusitis. The Veteran's private treatment records from 2012 to present are competent, credible, with significant probative weight. The Veteran's sinus issues were noted in July 1995, over a year after separation from service. The Veteran's private and VA treatment records as to his respiratory issues are competent, credible, with varying degrees of probative weight as noted above. significant probative weight. SLEEP DISTURBANCES The Veteran's VA medical records noted a sleep apnea diagnosis in private treatment in April 2008. The private sleep study was done in June 2006 which showed moderate OSA. The Veteran's OSA was diagnosed in 2006, 12 years after his separation from active service. The Board finds the Veteran's VA and private treatment records as to sleep disturbances to be competent, credible, and with significant probative weight. The Veteran's private and VA treatment records as to his sleep disturbances are competent, credible, with significant probative weight. VA EXAMINATIONS The Veteran received a urinary tract conditions VA examination in December 2019 that noted his ureter obstruction due to pelvic mass in service. The examiner found that the ureter obstruction was due to a pelvic mass and less likely due to a specific exposure event during the Veteran's SWA service. Additionally, the examiner noted no medical literature that support a correlation between the ureter obstruction due to pelvic mass and Gulf War exposures. The Board finds the VA examination to be competent, credible, and with significant probative weight. The Veteran received a Gulf War VA examination in December 2019 that noted his kidney and urinary tract conditions but indicated no other conditions. The examiner found that the Veteran's lymphoproliferative disorder represented a disease with a clear and specific etiology and diagnosis, and that the disorder was not related to a specific exposure event during SWA service. The examiner went on to indicate that there was no medical literature to support a correlation between lymphoproliferative disorder and SWA exposures. The examiner explained that medical literature listed viral infections as a possible trigger for the disorders, Epstein Barr virus infection was a documented possible cause of the disorders, but that there was no evidence that the disorders were due to chemical exposure in the Persian Gulf. The Board finds the VA examination to be competent, credible, and with significant probative weight. As discussed above the Veteran received a medical opinion for his OSA in June 2020 that found that the Veteran's complaint of trouble sleeping due to physical pain was different than OSA, which indicated a respiratory dysfunction. The examiner noted that when the Veteran was diagnosed with OSA in 2006 the Veteran's body mass index (BMI) was noted at 29.9 to 30.4; the overweight-obese category. The examiner indicated obesity was the number one risk factor in developing OSA as excess body weight caused increased pressure on upper airways leading to collapse and decreased neuromuscular control of the tongue causing airflow obstruction. The examiner found the Veteran's OSA was not due to sleep issues or exposures during service. The Board finds the VA examination to be competent, credible, and with significant probative weight. The Veteran received an additional GWS VA examination in September 2020 that noted the need for the Veteran to receive examinations for respiratory conditions, sinusitis/rhinitis conditions, hernia conditions, musculoskeletal and muscle injury conditions. The examiner noted that the Veteran had no conditions for which no etiology was established and no additional signs or symptoms not addressed through a completed VA examination. The Board finds the GWS VA examination to be competent, credible, and with significant probative weight. The Veteran received a respiratory conditions VA examination in September 2020 that noted his diagnosis of asthma in 2012. The Veteran reported being diagnosed with asthma in 2001 by a private doctor after coughing, sneezing, and having a running nose. The examiner noted the Veteran's daily inhaler and twice monthly inhaler. The examiner found that the Veteran's asthma was a disease with a clear and specific etiology and diagnosis. The examiner explained that asthma was one of the most common long-term disease of children, but adults can have asthma too. The examiner further opined that the Veteran's asthma was not related to a specific exposure event due to the Veteran's service in SWA. The Veteran was diagnosed with asthma 18 years after his separation from active duty and a nexus was not established. The Board finds the VA examination to be competent, credible, and with significant probative weight. The Veteran also received a sinus/rhinitis and other conditions of the nose, throat, larynx, and pharynx VA examination in September 2020. The Veteran's diagnoses of allergic rhinitis and acute sinusitis in 2012 were both noted. The Veteran reported in 1995 his nose was stuffy and he had headaches after returning from SWA and was placed on medication. He further indicated that his sinus had improved over the years and in 2012 was diagnosed with unspecified sinusitis. The examiner noted both sinusitis and rhinitis but noted no sinusitis symptoms and no rhinitis symptoms or findings. The examiner did note that allergic rhinitis was an incidental finding unrelated to the claimed condition. The examiner found after reviewing the Veteran's medical records, examining the Veteran, and review of current medical literature that the Veteran's sinusitis was a disease with a clear and specific etiology and diagnosis. Additionally, the examiner found that the Veteran's diagnosis was not related to a specific exposure event from his SWA service. The examiner explained that the Veteran was diagnosed with acute sinusitis in 2012, approximately 18 years after separation from service and no other evidence was noted to support complaints of sinus issues while in service, and therefore a nexus was not established. The Board finds the VA examination to be competent, credible, and with significant probative weight. The Veteran's hernia VA examination from September 2020, indicated above, noted the supraumbilical hernia diagnosis from 2016 and found no objective evidence of a ventral hernia and no diagnosis warranted. The examiner noted that they were unable to confirm a current chronic diagnosis of ventral hernia with available records and no nexus or secondary relationship was established. The Board finds the VA examination to be competent, credible, and with significant probative weight. The Veteran received a VA examination for muscle injuries in September 2020 that noted no diagnosis of muscle injuries. The examiner noted a disc condition in the Veteran's lower back but he denied any muscle injury with an onset of September 2020. The Veteran was found to have no muscle injuries, no muscle disability, normal muscle strength, no muscle atrophy, no assistive devices, and no functional impact. The examiner indicated that on the day of examination the Veteran was found to be within normal limits and no diagnosis was warranted. The examiner found that based on review of the medical literature, the Veteran's medical records, and the examination the Veteran was found not to have a diagnosis of joint muscle pain and therefore did not fall into any category of an undiagnosed illness, a MUCMI of unknown etiology, a diagnosable chronic multi-symptom illness with a partially explained etiology, nor a disease with a clear and specific etiology and diagnosis. The examiner found that the Veteran's claim of joint muscle pain had no connection to any exposures in SWA. The Board finds the VA examination to be competent, credible, and with significant probative weight. The Veteran received a mental health VA examination in September 2020 that indicated diagnosis of disruptive mood dysregulation disorder. The Veteran's diagnosis was described as sleep difficulty involving mid-sleep awakenings and worrying about day to day stressors, that he trusted no one and would not try to get close to others, including his spouse. The examiner noted the Veteran showed no incidents, complaints, or treatment of psychological issues while in service and no concerns noted previously in additional general medical examinations nor in his VA treatment records. The Veteran's symptoms of depressed mood, suspiciousness, near continuous panic or depression affecting his ability to function, chronic sleep impairment, mild memory loss, flattened affect, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful environment, and impaired impulse control were noted. The examiner found the Veteran did not meet the criteria for a sleep-related diagnosis due to exposures during service in SWA nor related to his military service. The examiner explained that the Veteran was endorsed with disruptive mood dysregulation disorder and his history suggested social problems, some issues with conduct prior to the military but no diagnosed mental health condition. The Veteran indicated negative social encounters in the military that appeared to the examiner to have undermined his faith in mankind and ability to trust others. The examiner noted the Veteran's behavioral trend emerged as a pattern of depressed irritability and a struggle to establish and maintain social relationships and occupational success. The Board finds the VA examination to be competent, credible, and with significant probative weight. ANALYSIS The Board finds that the signs or symptoms of respiratory issues, muscle pain, and sleep disturbances do not support a diagnosis of undiagnosed illness, a MUCMI, or a diagnosable chronic multi-symptom illness with a partially explained etiology. According to the multiple VA examinations above the Veteran's symptoms are explained by diagnoses of asthma, sinusitis, no joint muscle pain, multiple diagnoses of joint issues, and a psychiatric diagnosis as to sleep disturbances. The Veteran's service treatment records are devoid of any clear symptoms that are related to GWS or chronic symptomatology during the Veteran's active service. Due to this lack of diagnoses in service, the lack of chronic symptomatology, and the VA examinations above, the evidence suggests that the Veteran's symptoms did not manifest during, or as a result of active military service, to include his service in SWA. The Board acknowledges the Veteran's lay statements of respiratory issues, joint pain, and sleep disturbances. However, the aforementioned VA examiners found that the claimed disability of GWS was not a current diagnosable disability or not related to his exposure to SWA service. The examiners indicated that the respiratory issues were not related to service and were diagnosed after service, that the Veteran upon examination had no muscle injuries, and his sleep disturbances were due to a diagnosed psychiatric condition. The Board also notes that the Veteran has a current diagnosis of OSA as well. Therefore, in consideration of the VA examiner's findings and medical records of the Veteran, the medical evidence of record does not support a diagnosis of GWS. This lack of medical evidence precludes a finding of GWS as a chronic disability and precludes the finding of continuity of symptomatology. In addition, there is no medical evidence of record that any claimed respiratory issue, joint or muscle pain, or sleep disturbance experienced by the Veteran is due to an undiagnosed illness or exposures from service in SWA. Rather, the evidence of record has related the Veteran's symptomatology to known and diagnosed conditions or finding no symptoms at all. The Board also notes that the Veteran is already service connected for degenerative disc disease of his lumbar spine, radiculopathy of his right lower extremity, right patellofemoral syndrome of his right knee, and subluxation of his right knee. Also, the Veteran is not entitled to service connection for a medically unexplained chronic multi-symptom illness (MUCMI). Under the proper interpretation of the law, an illness or disease is a MUCMI where either the etiology or pathophysiology of the illness is inconclusive. Conversely, a condition is not a MUCMI where both the etiology and the pathophysiology of the illness are partially understood. In the present case, the Veteran's respiratory issues, joint and muscle pain, and sleep disturbance symptomatology has an etiology that is at least "partially understood," and as such, the Veteran's condition cannot be classified as a MUCMI. See 38 C.F.R. § 3.317 (a)(2)(ii). While the Veteran believes that his respiratory issues, joint and muscle pain and sleep disturbances are related to service in the Persian Gulf War, as a lay person, the Veteran has not shown that he has specialized training sufficient to render such an opinion with regard to this condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnoses or etiology of his claimed disabilities are a matter that is not capable of lay observation and requires medical expertise to determine. Accordingly, his opinion as to the diagnoses or etiology of his claimed disabilities is not competent medical evidence. Moreover, whether the injuries incurred in service are in any way related to his current disability is also a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the etiology of his current respiratory issues, joint and muscle pain, and sleep disturbances are not competent medical evidence. The Board finds the opinion of the VA examiners of record to be significantly more probative than the Veteran's lay assertions, as they are thorough in their review of the medical evidence of record and in their stated rationales. When there is an approximate balance between positive and negative evidence the benefit of the doubt doctrine must apply in favor of the Veteran. But when the preponderance of the evidence weighs against the claims of the Veteran the claim will be denied on its merits. The evidence before the Board here indicates that the Veteran's claim must be denied as the preponderance of the evidence is against the claim, and the benefit of the doubt doctrine is inapplicable. Therefore, the Veteran's claim of entitlement to service connection for GWS, to include symptoms related to an undiagnosed illness/MUCMI, to include as due to a service-connected disability, must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Therefore, the Veteran's claim for service connection for GWS to include as due to an undiagnosed illness or MUCMI as a result of SWA service is not warranted. REASONS FOR REMAND Entitlement to service connection for CKD, to include as secondary to service-connected disabilities The Veteran contends that he is entitled to service connection for his current CKD, to include as secondary to his service-connected residuals of lymphoid infiltrate. The Veteran's claim for service connection for CKD was reopened and remanded by the Board in April 2019. The Board's remand ordered a new VA examination which was provided in December 2019. The Board notes that the Veteran's record contains an August 1995 doctor letter from Dr. W. D. that indicated due to the ureter issue of the Veteran he had sustained kidney back pressure and damage to the right side which would require surgery to address the issue. The Veteran's VA treatment records also indicated normal kidney levels from 2002 to 2006 but documents from private doctors showed an ultrasound from June 2006 showing echogenicity consistent with CKD. The Veteran's VA treatment records of November 2011 noted the Veteran's CKD was asymptomatic. The Board finds that the August 1995 doctor letter and private and VA treatment records of the Veteran are competent, credible, and with significant probative weight. The Veteran in the September 2012 VA examination for urinary tract conditions contended that the kidney issues were due to the Veteran's pelvic mass, now service connected as residuals of lymphoid infiltrate. The Veteran received a VA examination for his CKD in June 2013 that did not address the Veteran's claim of his CKD being secondary to his service-connected residuals of lymphoid infiltrate. The examiner found that the Veteran's current CKD was not due to the Veteran's service-connected residuals for lymphoid infiltrate as the Veteran's renal condition was corrected with resection of the pelvic mass. The examiner further found that the Veteran's CKD was most likely related to chronic hypertension. However, the Board notes that the Veteran's representative in the October 2018 hearing indicated that the June 2013 VA examination was inadequate as there was a misrepresentation of the facts at that time as the Veteran did not have hypertension. As noted in the Board's remand in April 2019 a new VA examination was ordered. A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Board finds that the June 2013 VA examination to be inadequate for VA purposes. Pursuant to the Board remand in April 2019 the Veteran received a new VA examination for his kidney in December 2019 that noted the Veteran's diagnosis of hydronephrosis due to ureter obstruction from 1995. The examiner noted the Veteran's renal dysfunction but with no signs or symptoms of renal dysfunction, no regular dialysis, no hypertension or heart disease due to renal dysfunction or due to any kidney condition, no renal tubular disorder, no attacks of colic and no urolithiasis. The examiner also noted normal laboratory studies from December 2018 and December 2019. The examiner indicated that the Veteran's claimed hydronephrosis represented a disease with a clear and specific etiology and diagnosis that was less likely related to specific exposure event during his service in SWA and also found no medical literature to support a connection between hydronephrosis secondary to ureter obstruction and Gulf War exposures. The examiner found that the Veteran's kidney condition had completely resolved and pointed to the private March 2009 abdominal computerized tomography (CT) that documented a normal right kidney. The examiner further indicated that the Veteran did not have any kidney residuals nor disability related to the lymphoproliferative disease (residuals of lymphoid infiltrate). The Board finds that the December 2019 VA examination to be inadequate for VA purposes as the examiner's findings are conclusory and did not address whether the Veteran's CKD was caused by or aggravated by the residuals of lymphoid infiltrate. The examiner did not address the Veteran's statements, nor the August 1995 doctor's letter, nor the totality of the Veteran's medical records including being diagnosed with CKD. A current disability diagnosed at any point within the appeal period, even if the disability resolves during the appeal period (becomes asymptomatic) may be subject to service connection. See McClain v. Nicholson, 21 Vet. App. 219 (2007). Although further delay is regrettable, the Board finds that a remand is necessary in this case to ensure that due process is followed and that development is done on the remanded claims, and that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration and full compliance with the Board's previous remand instructions. 38 U.S.C. § 5103(A); 38 C.F.R. § 3.159; Stegall v. West, 11 Vet. App. 268, 270-71 (1998). The matter is REMANDED for the following actions: 1. The Veteran should be scheduled for a VA examination (a telehealth examination is also an option) before an appropriate physician regarding his claimed CKD and any other kidney condition. The Veteran's claims file and a copy of this remand must be provided to the examiner for review and the examination report should reflect that these items were available for review. After performing all indicated tests and studies, the examiner should address the following: (a.) Identify any and all kidney disorders that the Veteran currently suffers from, to include, but not exclude, CKD. Also identify any and all kidney disorders the Veteran has suffered from during his appeal period and list the dates as such. (b.) If a diagnosis of a kidney condition is assigned, please opine as to whether it is at least as likely as not that this condition manifested during, or as a result of, active military service. (c.) The examiner should also provide an opinion as to whether it is at least as likely as not that any diagnosed kidney condition or CKD was either caused by, or aggravated by, a service-connected disability. The term "aggravation" in the above context refers to a any incremental increase in disability any additional impairment of earning capacity in non-service connected disabilities resulting from service-connected conditions regardless of its permanence, beyond its natural progression, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. Ward v. Wilkie, 31 Vet. App. 233 (2019). In formulating the above opinions, the examiner must consider and discuss all lay statements and assertions provided by the Veteran. A complete rationale must be provided for any and all opinions offered. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must fully explain why this is the case and identify what, if any, additional evidence, or information might allow for a more definitive opinion. (CONTINUED NEXT PAGE) 2. Following completion of the foregoing, the Agency of Original Jurisdiction (AOJ) should review the record, perform any necessary development, and readjudicate the claim on appeal. If the appeal is denied, the AOJ should issue an appropriate Supplemental Statement of the Case (SSOC), afford the Veteran and his representative an opportunity to respond, and return the case to the Board. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C.A. Teich, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.