Citation Nr: 21040574 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 11-30 796 DATE: July 6, 2021 ORDER New and material evidence having been submitted, the claim of entitlement to service connection for left knee arthritis and chondrocalcinosis (hereinafter left knee disorder) is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for left shoulder arthritis is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for right shoulder arthritis is reopened. New and material evidence having been submitted, the claim of entitlement to service connection for peptic ulcer disease is reopened. Entitlement to an initial rating of 30 percent, but no higher, for fecal stress incontinence prior to December 9, 2016 is granted. Entitlement to an initial rating greater than 30 percent for fecal stress incontinence from December 9, 2016 is denied. REMANDED Entitlement to service connection for aortic stenosis is remanded. Entitlement to service connection for peptic ulcer disease, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for intestinal disorder, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for hemorrhoids, to include as due to herbicide agent exposure and/or as secondary to a service-connected disability, is remanded. Entitlement to service connection for lumbar spine degenerative joint disease and lumbar spine stenosis (hereinafter lumbar spine disorder), to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for left knee disorder, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for left shoulder arthritis, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for right shoulder arthritis, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for gout, to include as due to herbicide agent exposure and/or as secondary to a service-connected disability, is remanded. Entitlement to service connection for thoracic spine disorder, to include as due to herbicide agent exposure and/or as secondary to a service-connected disability, is remanded. Entitlement to service connection for gastroesophageal reflux disease (GERD), to include as due to herbicide agent exposure and/or as secondary to a service-connected disability, is remanded. Entitlement to service connection for bilateral thyroid lesions, to include as due to herbicide agent exposure and/or as secondary to a service-connected disability, is remanded. Entitlement to service connection for bile duct stenosis, to include as due to herbicide agent exposure and/or as secondary to a service-connected disability, is remanded. Entitlement to service connection for gallstones, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for liver disorder, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for hypertension, to include as due to herbicide agent exposure and/or as secondary to a service-connected disability, is remanded. Entitlement to service connection for bilateral renal cysts, to include as due to herbicide agent exposure and/or as secondary to a service-connected disability, is remanded. FINDINGS OF FACT 1. In an April 2009 rating decision, the Agency of Original Jurisdiction (AOJ) denied the Veteran's claims for service connection for left knee disorder, left shoulder arthritis, and right shoulder arthritis. The Veteran did not appeal or submit new and material evidence within a year of the decision. Therefore, the April 2009 rating decision became final. At the time of the April 2009 rating decision, the record did not contain the Veteran's assertion that his left knee and bilateral shoulder arthritis are related to in-service herbicide agent exposure, which potentially could establish the nexus element. This evidence is new and material and raises a reasonable possibility of substantiating the claims. 2. In a September 2009 Statement of the Case (SOC), the AOJ denied the Veteran's claim for service connection for peptic ulcer disease. The Veteran did not perfect his appeal; thus, the decision became final. At the time of the September 2009 SOC, the AOJ found the Veteran's peptic ulcer disease was not incurred in or caused by his service. At the time of the September 2009 decision the record did not contain the Veteran's assertion that his peptic ulcer disease is related to in-service herbicide agent exposure, which potentially could establish the nexus element. This evidence is new and material and raises a reasonable possibility of substantiating the claim. 3. For the entire period on appeal, the Veteran's fecal stress incontinence has been manifested by occasional involuntary bowel movements, necessitating wearing of a pad. Extensive leakage, fairly frequent involuntary bowel movements, and/or complete loss of sphincter control have not been demonstrated. CONCLUSIONS OF LAW 1. New and material evidence has been received to reopen the claim of entitlement to service connection for left knee disorder. 38 U.S.C. § 7105 (2018); 38 C.F.R. §§ 3.104, 3.156, 19.21 (2020). 2. New and material evidence has been received to reopen the claim of entitlement to service connection for left shoulder arthritis. 38 U.S.C. § 7105 (2018); 38 C.F.R. §§ 3.104, 3.156, 19.21 (2020). 3. New and material evidence has been received to reopen the claim of entitlement to service connection for right shoulder arthritis. 38 U.S.C. § 7105 (2018); 38 C.F.R. §§ 3.104, 3.156, 19.21 (2020). 4. New and material evidence has been received to reopen the claim of entitlement to service connection for peptic ulcer disease. 38 U.S.C. § 7105 (2018); 38 C.F.R. §§ 3.104, 3.156, 19.22 (2020). 5. The criteria for an initial 30 percent rating, but no higher, for fecal stress incontinence prior to December 9, 2016, have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7332 (2020). 6. The criteria for an initial rating greater than 30 percent for fecal stress incontinence from December 9, 2016, have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7332 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1970 to December 1971. He appeals September 2010 (fecal stress incontinence), September 2013 (GERD), May 2014 (liver disorder, bilateral renal cysts, bilateral thyroid lesions, and bile duct stenosis), February 2015 (gallstones, gout, and hypertension), and June 2015 (aortic stenosis, lumbar spine, intestinal disorder, hemorrhoids, thoracic spine, peptic ulcer disease, left knee, left shoulder, and right shoulder) rating decisions by the AOJ. In January 2018 and March 2019, the Board remanded the Veteran's claims of entitlement to service connection for neurovascular bundle of the rectum and for an initial rating for fecal stress incontinence for further development. Following the March 2019 Board remand, in December 2020, the AOJ awarded service connection for neurovascular bundle of the rectum, and the AOJ consolidated the condition with the Veteran's fecal stress incontinence based on the symptomatology of the conditions, effective July 23, 2015. The Veteran's claim for an increased rating for fecal stress incontinence is back before the Board for review, and the Board will evaluate the Veteran's symptoms attributed to his fecal stress incontinence since January 7, 2010, the date VA received the Veteran's claim for service connection for fecal stress incontinence, and will consider the Veteran's neurovascular bundle of the rectum since July 23, 2015, the effective date assigned by the AOJ. In March 2019, the Board reopened and remanded the Veteran's claims for gout, thoracic spine condition, and GERD for further development. The Board also remanded the Veteran's claims of entitlement to service connection for bilateral thyroid lesions, bile duct stenosis, gallstones, liver disorder, hypertension, and bilateral renal cysts. These claims are all back before the Board for further appellate proceedings. In addition, the Board remanded the Veteran's petition to reopen his claims for right knee disorder, peripheral vascular disorder (PVD) of the left upper extremity, and skin disability and claim of entitlement to service connection for urinary incontinence for the issuance of a SOC. The AOJ issued a SOC in August 2020 reopening and denying the Veteran's claim for right knee condition. The AOJ issued a separate SOC in August 2020 reopening and denying the Veteran's claims for PVD of the left upper extremity and skin disability and denying the Veteran's claim for urinary incontinence. The Veteran did not submit a substantive appeal for the claims following the August 2020 statements of the case, so the appeals are not before the Board. In the March 2019 decision, the Board noted that the Veteran filed a timely notice of disagreement (NOD) in July 2015 appealing the June 2015 rating decision denying the claim of entitlement to service connection for aortic stenosis. Furthermore, the March 2019 decision reflects that the Board did not remand the issue for a SOC since it appeared that the AOJ was working on the appeal. However, for the reasons noted below in the Remand section, the Board is remanding the Veteran's claim for service connection for aortic stenosis for the issuance of a SOC per Manlincon v. West, 12 Vet. App. 238 (1999). In the March 2019 decision, the Board noted that the Veteran filed a timely substantive appeal in response to the March 2018 SOC for the issues of entitlement to service connection for intestinal disorder and hemorrhoids and whether new and material evidence had been received to reopen previously denied claims of entitlement to service connection for peptic ulcer disease, lumbar spine disorder, and left knee disorder. The Board then noted that the AOJ had not informed the Veteran that the issues had been sent to the Board for appellate review; therefore, the Board determined that the issues were not currently on appeal before the Board. However, as the issues are ready for adjudication, the Board will address them at this time, irrespective of the issues not being certified to the Board. Likewise, the Veteran submitted a timely substantive appeal in April 2018 in response to the March 2018 SOC for the issues of whether new and material evidence had been received to reopen previously denied claims of left and right shoulder arthritis. The claims have not been certified to the Board. However, the record reflects that the issues are ready for adjudication. Therefore, they will be addressed by the Board at this time. Regarding the Veteran's claim for lumbar spine disorder, the Board notes that the Veteran filed a claim for service connection in March 2015 for "osteophyte" and "degenerative joint disease." In an April 2015 written statement, the Veteran listed his claims as "service connection for degenerative disc disease" and "service connection for degenerative arthritis." In the June 2015 rating decision, the AOJ in part denied claims of entitlement to service connection for lumbar spine degenerative disc disease, lumbar/thoracic spinal stenosis, and cervical spinal stenosis. The Veteran then submitted a timely NOD in July 2015 and in part appealed claims of entitlement to service connection for lumbar spine degenerative disc disease and lumbar/thoracic spinal stenosis. In a March 2018 SOC, the AOJ denied the claims of entitlement to service connection for lumbar spine degenerative disc disease and lumbar/thoracic spinal stenosis, and the Veteran appealed the claims to the Board in a timely April 2018 substantive appeal. In the March 2019 Board decision, the Board recharacterized the thoracic spine issue as a claim for any thoracic spine disorder to ensure that all potential diagnoses related to the thoracic spine are considered. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Likewise, the Board has recharacterized the issues of entitlement to service connection for lumbar spine degenerative disc disease and lumbar spinal stenosis as one issue of entitlement to service connection for any lumbar spine disorder to ensure that all potential diagnoses related to the lumbar spine are considered. Id. In addition, regarding the Veteran's left knee claim, the record contains diagnoses of left knee arthritis and chondrocalcinosis. Thus, the Board has recharacterized the issue of entitlement to service connection for left knee arthritis as entitlement to service connection for any left knee disorder to ensure that all potential diagnoses related to the left knee are considered. Id. Lastly, in the March 2019 Board decision, the Board denied the Veteran's claims of entitlement to service connection for PVD of the right upper extremity and PVD of the bilateral lower extremities. Notably, the AOJ issued a SSOC on March 22, 2019 denying claims of entitlement to service connection for PVD of the right upper extremity and PVD of the bilateral lower extremities, and the claims were certified to the Board on the same date. However, given that the Board denied the claims in the March 2019 decision, and that they have not returned to the Board through the proper appellate process, the Board does not have jurisdiction of the claims at this time. Thus, the Board will not address them further. Increased Rating Fecal Stress Incontinence The Veteran is seeking an initial rating in excess of 10 percent prior to December 9, 2016 and in excess of 30 percent thereafter for fecal stress incontinence. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. When considering the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection is required. See Fenderson v. West, 12 Vet. App. 199, 125-26 (1999). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings" whether it is an initial rating case or not. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Importantly, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. The Veteran's fecal stress incontinence is currently rated as 10 percent disabling prior to December 9, 2016 and 30 percent thereafter under Diagnostic Code 7332. In a December 2020 rating decision, the AOJ awarded service connection for neurovascular bundle of the rectum effective July 23, 2015. The AOJ noted that the Veteran's service-connected fecal stress incontinence and neurovascular bundle of the rectum are both evaluated under Diagnostic Code 7332, so the AOJ assigned one 30 percent rating for fecal stress incontinence with neurovascular bundle of the rectum to avoid impermissible pyramiding. See 38 C.F.R. § 4.14 ("[t]he evaluation of the same disability under various diagnoses, "a practice called 'pyramiding,'" is to be avoided); Brady v. Brown, 4 Vet. App. 203, 206 (1993) (the rationale for the prohibition on pyramiding is that "the rating schedule may not be employed as a vehicle for compensating a claimant twice (or more) for the same symptomatology; such a result would overcompensate the claimant for the actual impairment" suffered). Under Diagnostic Code 7332, a 10 percent rating is warranted for constant slight or occasional moderate leakage. A 30 percent rating is warranted for occasional involuntary bowel movements, necessitating the wearing of a pad. A 60 percent rating is warranted for extensive leakage and fairly frequent involuntary bowel movements. A maximum 100 percent rating is warranted for complete loss of sphincter control. 38 C.F.R. § 4.114. Based on the evidence, the Board finds that the Veteran is entitled to a 30 percent rating, but no higher, throughout the rating period for his fecal stress incontinence, as the evidence illustrates that the Veteran has had occasional involuntary bowel movements, necessitating wearing a pad. See December 2016 and December 2019 VA examination reports. The Board acknowledges that the medical records prior to December 2016 do not show that the Veteran wore a pad due to his fecal stress incontinence. However, in a March 2011 written statement, the Veteran stated that his pad for his urine incontinence takes care of both his urine and fecal incontinence issues. Furthermore, in a March 2011 written statement accompanying the notice of disagreement (NOD), the Veteran's former spouse stated that the Veteran wears pads every day in part for fecal incontinence. See March 2011 NOD at 4. She also stated that she saw evidence of fecal incontinence when she did the Veteran's laundry. Id. In addition, the Veteran stated at his December 2016 VA examination that his condition has stayed the same. Based on the competent and credible testimony at his December 2016 VA examination that his fecal stress incontinence has stayed the same, the competent evidence of the finding of occasional involuntary bowel movements at December 2016 VA examination, and the competent and credible evidence from the Veteran and his former spouse that he has worn pads for his fecal incontinence throughout the appeal period, the Board concludes that an initial 30 percent rating is warranted throughout the appeal period. As there is no indication of extensive leakage, frequent involuntary bowel movements, or complete loss of sphincter control, a rating in excess of 30 percent is not warranted at any period. See December 2016 and December 2019 VA examination reports. Accordingly, the criteria for a 30 percent rating, but no higher, for the Veteran's fecal stress incontinence throughout the appeal period have been met. REASONS FOR REMAND 1. Aortic Stenosis In a June 2015 rating decision, the AOJ denied the Veteran's claim of entitlement to service connection for aortic stenosis. The Veteran submitted a timely NOD in July 2015 appealing his claim for service connection for aortic stenosis. Thereafter, in a March 2018 SOC, the AOJ informed the Veteran that his July 2015 NOD was unclear as to whether he was filing a NOD regarding his aortic stenosis, and the AOJ informed the Veteran that no further action would be taken unless the AOJ received clarification from the Veteran. An August 2020 deferred rating decision reflects that the AOJ was aware of the July 2015 NOD and was working on the appeal. However, a review of the record since the August 2020 deferred rating decision illustrates that no action has been taken on the Veteran's claim of entitlement to service connection for aortic stenosis. Thus, as the Veteran properly filed a timely NOD for his claim for service connection for aortic stenosis per 38 C.F.R. §§ 19.20 and 19.21, a remand of the claim is warranted for the AOJ to issue a SOC. See Manlincon, 12 Vet. App. 238. 2. Peptic Ulcer Disease and Intestinal Disorder The Board cannot make a fully-informed decision on the issues of entitlement to service connection for peptic ulcer disease and intestinal disorder because no VA examiner has opined whether the Veteran has peptic ulcer disease and/or an intestinal disorder that is related to his service or secondary to a service-connected disability. Thus, a remand is required to obtain a VA examination and opinion as to the nature and etiology of any peptic ulcer disease and intestinal disorder. 3. Hemorrhoids The Board cannot make a fully-informed decision on the issue of entitlement to service connection for hemorrhoids because no VA examiner has opined whether the Veteran's diagnosed hemorrhoids are related to his service or secondary to a service-connected disability. Thus, a remand is required to obtain a VA opinion as to the etiology of the Veteran's hemorrhoids. 4. Lumbar Spine Disorder The Board cannot make a fully-informed decision on the issue of entitlement to service connection for lumbar spine disorder because no VA examiner has opined whether the Veteran has lumbar spine disorder that is related to his service. Here, the Board notes that a May 2013 chest CT showed degenerative changes of the thoracic spine, a November 2013 chest CT showed mild multilevel degenerative changes in the spine, an April 2014 chest CT showed degenerative changes of the spine, and a December 2019 VA examination report for the Veteran's thoracic spine contains a diagnosis of degenerative arthritis of the spine. However, there is no specific mention of lumbar spine degenerative joint disease, a remand is required to obtain a lumbar spine VA examination to determine if the Veteran has a lumbar spine disorder, and if so, whether such disability is related to his service. 5. Left Knee Arthritis, Left Shoulder Arthritis, and Right Shoulder Arthritis The Board cannot make a fully-informed decision on the issue of entitlement to service connection for left knee and bilateral shoulder arthritis because no VA examiner has opined whether the Veteran's diagnosed left knee and bilateral shoulder arthritis are related to his service. Thus, a remand is required to obtain a VA opinion as to the etiology of the Veteran's left knee disorder, left shoulder arthritis, and right shoulder arthritis. 6. Gout, Thoracic Spine Disorder, GERD, Bilateral Thyroid Lesions, Bile Duct Stenosis, Gallstones, Liver Disorder, Hypertension, and Bilateral Renal Cysts The Board regrets the additional delay, but an additional remand for further development is required to adequately evaluate the Veteran's claims in this section. The Board remanded these claims in March 2019 to obtain additional medical opinions as to whether the Veteran's disabilities are related to service, to include exposure to herbicide agents. A VA examiner provided negative medical opinions in January 2020, but the examiner relied on the conditions in this section not being conditions in which presumptive service connection is warranted for herbicide agent exposure. See 38 C.F.R. § 3.309(e). In December 2020, a VA examiner provided negative opinions regarding the Veteran's bilateral thyroid lesions, GERD, gout, and thoracic spine disorder. In January 2021, a different VA examiner from the December 2020 VA examiner provided negative opinions regarding the Veteran's bilateral thyroid lesions, GERD, gout, thoracic spine disorder, bile duct stenosis, liver disorder, gallstones, and bilateral renal cysts. A review of the opinions issued in January 2020, December 2020, and January 2021 illustrates that the opinions contain insufficient rationale to adequately evaluate the Veteran's claims for service connection. As such, an additional remand is required to obtain VA opinions regarding the etiology of the Veteran's claims of entitlement to service connection for gout, thoracic spine disorder, GERD, bilateral thyroid lesions, bile duct stenosis, gallstones, liver disorder, hypertension, and bilateral renal cysts. The Board notes that the March 2021 VA opinion as to whether the Veteran's hypertension is directly related to service is adequate for evaluation purposes. However, the Veteran has contended that his hypertension is secondary to his service-connected type II diabetes mellitus and prostate cancer and his nonservice-connected thyroid and kidney disorders that are being remanded herein. A January 2020 VA opinion as to whether the Veteran's service-connected type II diabetes mellitus caused or aggravated his hypertension is insufficient for adjudication purposes because the examiner provided no rationale in support of the aggravation opinion. Furthermore, there is no opinion in the record as to whether the Veteran's service-connected prostate cancer has caused or aggravated his hypertension. In addition, because a decision on the remanded issues of entitlement to service connection for bilateral thyroid lesions and bilateral renal cysts could significantly impact a decision on the issue of service connection for hypertension, the issues are inextricably intertwined. Thus, a remand of the claim for hypertension is required. The matters are REMANDED for the following actions: 1. Send the Veteran a SOC that addresses the issue of entitlement to service connection for aortic stenosis. Notify the Veteran and his representative of his appellate rights. If the Veteran perfects a timely substantive appeal, the issue should be returned to the Board for further appellate consideration. 2. Obtain any outstanding VA and/or private treatment records relevant to treatment the Veteran received for his conditions being remanded herein that are not already of record. All obtained records should be associated with the evidentiary record. If any identified records are not obtainable (or none exist), the Veteran should be notified, and the record clearly documented. 3. After completing the development above, schedule the Veteran for an examination from an appropriately qualified VA examiner to determine the nature and etiology of his peptic ulcer disease and intestinal condition. Also, obtain a medical opinion as to the etiology of the Veteran's hemorrhoids, GERD, bilateral thyroid lesions, bile duct stenosis, gallstones, liver disorder, and bilateral renal cysts. It is up to the discretion of the examiner as to whether a new examination is necessary to provide an adequate opinion regarding the Veteran's hemorrhoids, GERD, bilateral thyroid lesions, bile duct stenosis, gallstones, liver disorder, and/or bilateral renal cysts. The evidentiary record, including a copy of this remand, must be made available to and be reviewed by the examiner. After the record review and any additional examinations deemed necessary, aside from the ones specifically ordered above, the examiner is asked to respond to the following inquiries: A. Does the Veteran have a diagnosis of peptic ulcer disease or any symptoms that cause functional impairment of earning capacity? In addressing this, it is noted that the Veteran contended in a March 2015 written statement that his peptic ulcer disease is secondary to helicobacter pylori, which was identified in an April 2013 biopsy. B. For any peptic ulcer disease/functional loss, is it at least as likely as not that such, was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's peptic ulcer disease/functional loss is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. C. For any peptic ulcer disease/functional loss, is it at least as likely as not that such was caused or aggravated by a service-connected disability? D. Identify all intestinal disorders aside from the intestinal disorders already diagnosed (hemorrhoids, GERD, bile duct stenosis, fecal stress incontinence, neurovascular bundle of the rectum, gallstones, and liver disorder). E. For any intestinal disorder(s)/functional loss other than hemorrhoids, GERD, bile duct stenosis, fecal stress incontinence, neurovascular bundle of the rectum, gallstones, and liver disorder, is it at least as likely as not that such intestinal disorder(s), was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the additional intestinal disorder(s)/functional loss is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. F. Is it at least as likely as not that the Veteran's hemorrhoids, were incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's hemorrhoids are not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. G. Is it at least as likely as not that the Veteran's hemorrhoids were caused or aggravated by his service-connected prostate cancer or type II diabetes mellitus? H. Is it at least as likely as not that the Veteran's GERD, was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's GERD is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. I. Is it at least as likely as not that the Veteran's GERD was caused or aggravated by his service-connected type II diabetes mellitus? In addressing this question, the examiner is asked to consider the medical literature the Veteran submitted in April 2018 regarding the relationship between GERD and diabetes. J. Is it at least as likely as not that the Veteran's bilateral thyroid lesions, were incurred in, or are otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's bilateral thyroid lesions are not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. K. Is it at least as likely as not that the Veteran's bilateral thyroid lesions were caused or aggravated by his service-connected prostate cancer? L. Is it at least as likely as not that the Veteran's bile duct stenosis, was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's bile duct stenosis is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. M. Is it at least as likely as not that the Veteran's gallstones, were incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's gallstones are not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. N. Is it at least as likely as not that the Veteran's liver disorder (diagnosed as liver periportal inflammation with eosinophils and hypodense lesions), was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's liver disorder is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. O. Is it at least as likely as not that the Veteran's bilateral renal cysts, were incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's bilateral renal cysts are not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. P. Is it at least as likely as not that the Veteran's bilateral renal cysts were caused or aggravated by his service-connected type II diabetes mellitus? In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 4. After completing the development above, schedule the Veteran for an examination from an appropriately qualified VA examiner to determine the nature and etiology of his lumbar spine condition. Also, obtain a medical opinion as to the etiology of the Veteran's left knee, bilateral shoulder, thoracic spine, and gout disabilities. It is up to the discretion of the examiner as to whether a new examination is necessary to provide an adequate opinion regarding the Veteran's left knee, bilateral shoulder, thoracic spine, and/or gout disabilities. The evidentiary record, including a copy of this remand, must be made available to and be reviewed by the examiner. After the record review and any additional examinations deemed necessary, aside from the one specifically ordered above, the examiner is asked to respond to the following inquiries: A. Provide diagnoses of any lumbar spine disorder or any symptoms that cause functional impairment of earning capacity? In addressing this, it is noted that a May 2013 chest CT showed degenerative changes of the thoracic spine, a November 2013 chest CT showed mild multilevel degenerative changes in the spine, an April 2014 chest CT showed degenerative changes of the spine, and a December 2019 VA examination report for the Veteran's thoracic spine contains a diagnosis of degenerative arthritis of the spine. B. For any lumbar spine disorder/functional loss, is it at least as likely as not that such, was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's lumbar spine disorder/functional loss is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. C. Is it at least as likely as not that the Veteran's left knee disorder (diagnosed as degenerative changes and chondrocalcinosis), was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's left knee disorder is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. D. Is it at least as likely as not that the Veteran's left shoulder arthritis, was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's left shoulder arthritis is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. E. Is it at least as likely as not that the Veteran's right shoulder arthritis, was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's right shoulder arthritis is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. F. Is it at least as likely as not that the Veteran's thoracic spine disorder (diagnosed as degenerative arthritis), was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's thoracic spine disorder is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. G. Is it at least as likely as not that the Veteran's thoracic spine disorder was caused or aggravated by his service-connected type II diabetes mellitus with erectile dysfunction, prostate cancer, or fecal stress incontinence with neurovascular bundle of the rectum? H. Is it at least as likely as not that the Veteran's gout, was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's gout is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. I. Is it at least as likely as not that the Veteran's gout was caused or aggravated by his service-connected type II diabetes mellitus with erectile dysfunction, prostate cancer, or fecal stress incontinence with neurovascular bundle of the rectum? In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 5. After completing the development above, obtain an opinion from a qualified clinician to determine the nature and etiology of the Veteran's hypertension. The evidentiary record, including a copy of this remand, must be made available to and be reviewed by the reviewing clinician. It is up to the discretion of the reviewing clinician as to whether a new examination is necessary to provide an adequate opinion. After the record review and examination of the Veteran, if deemed necessary, the reviewing clinician is asked to respond to the following inquiries: A. Is it at least as likely as not that the Veteran's hypertension, was incurred in, or is otherwise related to, his time on active service, to include conceded exposure to herbicide agents? It is not sufficient to provide an opinion that the Veteran's hypertension is not directly due to herbicide agent exposure merely because it is not a disease on the list of diseases and conditions presumptively linked with herbicide agent exposure. B. Is it at least as likely as not that the Veteran's hypertension was caused or aggravated by his service-connected type II diabetes mellitus or prostate cancer? In rendering these opinions, the reviewing clinician is advised that the Veteran is competent to report his symptoms and history, including as to why he did not receive treatment for his low back disability in service or after his discharge from service. Such reports must be acknowledged and considered in formulating any opinion. If the reviewing clinician rejects the Veteran's reports, he or she must provide an explanation for such rejection. The reviewing clinician is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the reviewing clinician must provide a complete explanation for why an opinion cannot be rendered. In so doing, the reviewing clinician must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 6. After the above development has been completed, readjudicate the claims. If any benefit sought remains denied, provide the Veteran with a SSOC, and return the case to the Board, if otherwise in order. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Breitbach, 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.