Citation Nr: 21040679 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 19-39 146 DATE: July 6, 2021 ORDER Entitlement to service connection for bilateral hearing loss is granted. Entitlement to service connection for prostate cancer is denied. REMANDED Entitlement to service connection for kidney disease is remanded. Entitlement to service connection for erectile dysfunction is remanded. Entitlement to service connection for a distended or weakened bladder is remanded. Entitlement to service connection for cytomegalovirus is remanded. Entitlement to service connection for hypothyroidism is remanded. Entitlement to service connection for rheumatoid arthritis is remanded. FINDINGS OF FACT 1. The Veteran has a current bilateral hearing loss disability for VA compensation purposes that is consistent with his in-service noise exposure. 2. The Veteran's prostate cancer, did not manifest during the Veteran's military service, is not otherwise related to an event or injury in service, to include claimed exposure to ionizing radiation; and did not manifest to a compensable level within one year of his discharge from service. CONCLUSIONS OF LAW 1. Resolving doubt in the Veteran's favor, the criteria for service connection for a bilateral hearing loss disability are met. 38 U.S.C. § § 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. Prostate cancer was not incurred in active service and may not be presumed to have been so incurred. 38 U.S.C. § 1110, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.159, 3.303, 3.307, 3.309, 3.311 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1956 to March 1959. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2018 rating decision from a Department of Veterans Affairs Regional Office (RO). The Board also notes that in an unappealed and final October 2013 rating action, the RO denied service connection for prostate cancer, erectile dysfunction, kidney disease and a distended bladder. After issuance of the October 2013 final rating action, the RO received additional service treatment records in December 2017. Thus, in the instant appeal, the Board will consider the Veteran's claims for service connection for prostate cancer, erectile dysfunction, kidney disease and a distended bladder without requiring new and material evidence. Thus, the issues have been framed as indicated on the title page. 38 C.F.R. § 3.156(c) (2020). Service Connection Laws and Regulations Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain diseases, to include sensorineural hearing loss, prostate cancer and arthritis may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as sensorineural hearing loss, prostate cancer and arthritis is through a demonstration of continuity of symptomatology. Service connection for disability that is claimed to be attributable to exposure to ionizing radiation during service can be demonstrated by three different methods. See Davis v. Brown, 10 Vet. App. 209, 211 (1997); Rucker v. Brown, 10 Vet. App. 67, 71 (1997). First, there are certain types of cancer that are presumptively service connected specific to radiation-exposed veterans. 38 U.S.C. § 1112(c); 38 C.F.R. § 3.309(d). Second, "radiogenic diseases" may be service connected pursuant to 38 C.F.R. § 3.311. Third, service connection may be granted under 38 C.F.R. § 3.303(d) when it is established that the disease diagnosed after discharge is the result of exposure to ionizing radiation during active service. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). A "radiation-exposed veteran" is defined by 38 C.F.R. § 3.309 (d)(3) as a veteran who, while serving on active duty or on active duty for training or inactive duty training, participated in a radiation-risk activity. A "radiation-risk activity" includes the onsite participation in a test involving the atmospheric detonation of a nuclear device. 38 C.F.R. § 3.309 (d)(3)(ii)(A). The term "onsite participation" means presence at the test site, or performance of military duties in connection with ships, aircraft, or other equipment used in direct support of the nuclear test, during the official operational period of an atmospheric nuclear test. 38 C.F.R. § 3.309 (d)(3)(iv)(A). For tests conducted by the United States, the term "operational period" for Operation CASTLE means the period March 1, 1954, through May 31, 1954. 38 C.F.R. § 3.309 (d)(3)(v)(J). First, diseases specific to radiation-exposed veterans are the following: leukemia (other than chronic lymphocytic leukemia), thyroid cancer, breast cancer, cancer of the pharynx, esophageal cancer, stomach cancer, cancer of the small intestine, pancreatic cancer, multiple myeloma; lymphomas (except Hodgkin's disease), cancer of the bile ducts, cancer of the gall bladder, primary liver cancer (except if cirrhosis or hepatitis B is indicated), salivary gland cancer, cancer of the urinary tract, bronchio-alveolar carcinoma, bone cancer, brain cancer, colon cancer, lung cancer, and ovarian cancer. 38 C.F.R. § 3.309(d) (2). Second, 38 C.F.R. § 3.311 provides instruction on the development of claims based on exposure to ionizing radiation. Section 3.311(a) calls for the development of a dose assessment where it is established that a radiogenic disease first became manifest after service, where it was not manifest to a compensable degree within any applicable presumptive period specified in either § 3.307 or § 3.309, and where it is contended that the disease is a result of ionizing radiation in service. Dose data will be requested from the Department of Defense in claims based upon participation in atmospheric nuclear testing, and claims based upon participation in the American occupation of Hiroshima or Nagasaki, Japan, prior to July 1, 1946. 38 C.F.R. § 3.311(a) (2). In all other claims involving radiation exposure, a request will be made for any available records concerning the veteran's exposure to radiation. These records normally include but may not be limited to the veteran's Record of Occupational Exposure to Ionizing Radiation (DD Form 1141), if maintained, service medical records, and other records which may contain information pertaining to the veteran's radiation dose in service. All such records will be forwarded to the Under Secretary for Health, who will be responsible for preparation of a dose estimate, to the extent feasible, based on available methodologies. 38 C.F.R. § 3.311(a) (2) (iii). For all claims where radiation exposure during service is claimed and a radiogenic disease is diagnosed after service, 38 C.F.R. § 3.311 (2019) compels the forwarding of all records pertaining to the Veteran's radiation exposure in service to the Under Secretary for Health. The Under Secretary of Health is responsible for the preparation of a dose estimate, to the extent feasible, based on available methodologies. 38 C.F.R. § 3.311(a) (2) (iii). After it is determined by the dose assessment that the Veteran was exposed to radiation, the RO is then required to refer the case to the Under Secretary for Benefits for further consideration. 38 C.F.R. § 3.311(b) (2019). When the claim is referred, the Under Secretary for Benefits shall consider the claim with reference to the factors specified in 38 C.F.R. § 3.311(e) and may request an advisory opinion from the Under Secretary for Health. 38 C.F.R. § 3.311(c) (1) (2019). After referral, the Under Secretary for Benefits must then determine the likelihood that the claimant's exposure to radiation in service resulted in the radiogenic disease. 38 C.F.R. § 3.311(c) (1) (2020). This section provides two options: (i) If after such consideration the Under Secretary for Benefits is convinced sound scientific and medical evidence supports the conclusion it is at least as likely as not the Veteran's disease resulted from exposure to radiation in service, the Under Secretary for Benefits shall so inform the regional office of jurisdiction in writing. The Under Secretary for Benefits shall set forth the rationale for this conclusion, including an evaluation of the claim under the applicable factors specified in paragraph (e) of this section. (ii) If the Under Secretary for Benefits determines there is no reasonable possibility that the Veteran's disease resulted from radiation exposure in service, the Under Secretary for Benefits shall so inform the regional office of jurisdiction, in writing, setting forth the rationale for this conclusion. 38 C.F.R. § 3.311(c) (1) (2020). Third, and notwithstanding the above, when a veteran is found not to be entitled to a regulatory presumption of service connection for a given disability, the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See Combee, 34 F.3d at 1043-1044. Thus, the Board must not only determine whether the Veteran has a disability which is recognized by VA as being etiologically related to exposure to ionizing radiation, but must also determine whether his disability is otherwise the result of active service. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). Bilateral Hearing Loss For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Tests are less than 94 percent. 38 C.F.R. § 3.385. Additionally, it is noted that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Factual Background and Analysis The Veteran's service treatment records are negative for complaints of, treatment for, or findings of bilateral hearing loss or tinnitus. The Veteran's August 1956 enlistment examination and February 1959 separation examination noted whisper test results of 15/15 in both ears. The Veteran underwent a VA examination in February 2018. The February 2018 audiogram revealed pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 40 50 75 LEFT 20 20 45 60 75 The examiner opined that it was less likely than not that the Veteran's bilateral hearing loss was caused by or the result of an in event in military service. The examiner noted that at his enlistment and separation, the Veteran was administered whisper tests which were not a reliable indicator of hearing. The examiner noted a lack of audiological care during and after service and as a result, a nexus could not be established. The Veteran reported tinnitus that began in 1958 after he was exposed to 3 bomb testings. The examiner opined that it was at least as likely as not that the Veteran's tinnitus was related to his in-service noise exposure as the Veteran was exposed to excessive noise exposure during service and excessive noise was to cause tinnitus. An April 2018 VA audiological note indicated that the Veteran reported excessive noise during his military service and that he noticed a gradual progression of hearing loss. The record shows that the Veteran currently has bilateral hearing loss for VA compensation purposes. Accordingly, the first element of evidence of a current disability is accordingly met. Therefore, the question to be decided in the present appeal is whether the current bilateral hearing loss disability is associated with the Veteran's active duty. In this regard, the Board acknowledges that service treatment records are negative for complaints of, treatment for, or findings of hearing loss. However, when considering the circumstances of the Veteran's service, he was undoubtedly exposed to some noise in service. After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for bilateral hearing loss is warranted. In support of this conclusion, the Board notes that the Veteran's conceded in-service noise exposure was sufficient to result in a grant of service connection for bilateral tinnitus in a March 2018 rating decision. This grant was based on the positive nexus opinion of the February 2018 VA examiner who expressly conceded in-service noise exposure. The Board acknowledges that the February 2018 VA examiner opined that it was less likely than not that the Veteran's bilateral hearing loss was caused by or the result of his military service. However, the negative nexus opinion that was provided by the February 2018 VA examiner appears to be based in large part on the absence of documented bilateral hearing loss in the Veteran's service treatment records as the VA examiner again found that the Veteran's bilateral hearing loss was less likely than not caused by or a result of military service since there was no hearing loss in service. The Board finds that this examination is not inadequate. The absence of documented hearing loss in service is not fatal to a service connection claim for hearing loss. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Moreover, the fact that the Veteran has been diagnosed as having tinnitus as a result of his in-service noise exposure and granted compensation for tinnitus adds to the credibility of the Veteran's contention that his bilateral hearing loss disability is related to service because "an associated hearing loss is usually present" with tinnitus. The Merck Manual, Sec. 7, Ch. 82, Approach to the Patient with Ear Problems. Further, tinnitus may occur as a symptom of nearly all ear disorders including sensorineural or noise-induced hearing loss. Id. With regard to the latter, the evidence of record reflects that the Veteran's tinnitus is noise-induced, i.e., a result of his exposure to acoustic trauma during service. In this regard, the Board notes that "high frequency tinnitus usually accompanies [noise-induced] hearing loss." The Merck Manual, Section 7, Ch. 85, Inner Ear. Additionally, while the February 2018 VA examiner opined that the Veteran's bilateral hearing loss was not a result of in-service noise exposure, he again indicated that the Veteran's tinnitus was related to in-service noise exposure. As a result, the Board finds that there is an approximate balance of positive and negative evidence regarding the question of whether the Veteran had a current bilateral hearing loss disability that was caused by his service. In sum, for the reasons and bases discussed above, the Board has resolved doubt in favor of the Veteran, and service connection for a bilateral hearing loss disability is granted. See 38 U.S.C. § 5107(b). Prostate Cancer Factual Background and Analysis The Veteran contends that his prostate cancer disability was the result of in-service radiation exposure. Specifically, he contends that he was involved with post-Operation REDWING and Operation HARDTACK at the Eniwetok Atoll in 1948. The Veteran's service treatment records were negative for complaints or diagnoses for a prostate disability. Initially, the Board notes that the Veteran's service personnel records confirm that he participated in post-Operation REDWING and Operation HARDTACK during the requisite operational period. However, prostate cancer is not a disease presumptively service connected for radiation-exposed veterans under the provisions of 38 C.F.R. § 3.309 (d)(2). Accordingly, the presumptive provisions of 38 C.F.R. § 3.309 (d) are not for application in this case. The record shows that the Veteran had been diagnosed with prostate cancer, which is a radiogenic disease as defined under 38 C.F.R. § 3.311 (b)(2)(xxiii). In addition, the Veteran indicated that this radiogenic disease manifested more than five years after his claimed exposure. See 38 C.F.R. § 3.311 (b)(5)(iv). Thus, the Veteran was provided with the special development procedures of this section. In compliance with 38 C.F.R. § 3.311, in August 2013, the Defense Threat Reduction Agency (DTRA) confirmed that the Veteran was a participant of post-Operation REDWING and Operation HARDTACK and provided a radiation dose assessment using an expedited methodology based on worst-case doses. DTRA explained that the expedited process established conservative theoretical maximum doses utilizing actual radiation measurement and technical calculations from atmospheric nuclear test detonations, previously established doses, bounding assumptions about exposure scenarios, and radiation science fundamentals. It was also noted that the maximum doses were much higher than doses that were estimated in previous radiation dose assessments in order to provide maximum benefit of the doubt to the Veteran and to ensure that the reported doses were not less than actual doses. DTRA further explained that the worst-case parameters and assumptions should adequately encompass any activities that the Veteran performed. Moreover, it was noted that input from the Veteran was carefully reviewed to ensure that no activities reported would result in a higher dose than that generated through the expedited process. The Veteran's dose estimate was as follows: 18 rem external gamma; 0.5 rem external neutron; 4.5 rem internal committed dose to the prostate (alpha); and 2 internal committed dose to the prostate (beta plus gamma). In September 2013, the Director, Post 9-11 Era Environmental Health Program (DEHP), in a written Memorandum written for the Director of Compensation Service, noted that the Veteran's prostate cancer was first diagnosed in 2003. The Director indicated that it was unlikely that the Veteran's prostate cancer could be attributed to ionizing radiation in service. The Memorandum noted that the Interactive Radioepidemiological Program (IREP) was used to estimate the likelihood that exposure to ionizing radiation was responsible for the Veteran's cancer and that the program calculated a 99th percentile value for the probability of causation of 27.53 percent for prostate cancer. In September 2013, the Director of Compensation Service opined that, based on the opinion provided on behalf of the Under Secretary of Health, and following review of the evidence in its entirety, there was no reasonable possibility that the Veteran's prostate cancer resulted from radiation exposure in service. The Director noted that the Veteran was first exposed to ionizing radiation at age 19 while his prostate cancer was first diagnosed 46 years after the exposure and that there was a family history of prostate cancer. As a result of the above findings, the Board finds that entitlement to service connection for prostate cancer is not established pursuant to the provisions of 38 C.F.R. § 3.311. Although it is conceded that the Veteran had a radiogenic disease as specified under 38 C.F.R. § 3.311 (b)(1)(2), which manifested within the period specified by regulation, and was exposed to ionizing radiation as the result of his participation in post-Operation REDWING and Operation HARDTACK, the evidence does not demonstrate that the Veteran's exposure to ionizing radiation caused his current prostate cancer. As noted above, the opinion provided by the Director of the Post-9/11 Environmental Health Service considered the Veteran's medical history, the nature of his exposure to ionizing radiation, and the radiation dose information when finding that it was unlikely that the Veteran's prostate cancer could be attributed to ionizing radiation in service. The Board additionally finds that the appropriate development for radiogenic diseases has been completed as set out under 38 C.F.R. § 3.311 (b). As the opinion obtained pursuant to that development does not relate prostate cancer to exposure to ionizing radiation in service, the Board finds that service connection for prostate cancer is not warranted under those provisions. Accordingly, his claim must now be reviewed to determine if service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994) (holding that the Veterans' Dioxin and Radiation Exposure Compensation Standards (Radiation Compensation) Act, Pub. L. No. 98-542, § 5, 98 Stat. 2724, 2727-29 (1984), does not preclude a Veteran from establishing service connection with proof of actual direct causation). When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for prostate cancer residuals is not warranted on a presumptive or direct basis. At the outset, the Board notes that while prostate cancer is a disease that warrants service connection on a presumptive basis if manifested within one year of service separation, the record does not demonstrate a diagnosis of prostate cancer within a year of service separation. Accordingly, service connection on a presumptive basis may not be granted as the prostate cancer was not shown in service or within one year of discharge therefrom. See 38 C.F.R. §§ 3.307, 3.309. As noted above, while the Veteran separated from service in March 1959, the evidence demonstrates that his prostate cancer was first diagnosed in 2003. As the Veteran was not diagnosed with a prostate disability until many years after service and there was a significant period between his service and his post-service complaints where the medical record was silent for complaints of a prostate disability, the Board concludes that the weight of the evidence is against a finding of any continuity of symptomatology. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Regarding service connection on a direct basis, the Board finds that the evidence is against a finding that the Veteran's prostate cancer residuals are otherwise etiologically related to his service. The Board again notes that the Veteran's service treatment records were negative for complaints or diagnoses for a prostate disability. Further, there is no competent evidence or opinion otherwise suggesting that there exists a medical nexus between the Veteran's prostate cancer disability and his service to include as secondary to radiation exposure and neither the Veteran nor his representative had presented or identified any such existing medical evidence or opinion. Notably, while the Veteran maintains that his prostate cancer was due to exposure to ionizing radiation during his active service, the Veteran again did not claim to have sought in-service treatment for prostate complaints. Consequently, the Board finds the determination made as result of the application of the Compensation and Pension instructions regarding the adjudicating of prostate cancer claims to be more probative. The Board finds that the competent evidence of record, while showing the currently diagnosed disability of prostate cancer, does not demonstrate that prostate cancer manifested to a compensable degree within one year of separation. Additionally, there is no competent evidence that a prostate cancer disability is related to the Veteran's service to include as secondary to radiation exposure. To the extent that the Veteran contends that a medical relationship exists between his claimed current prostate cancer disability and service, the Board finds that the Veteran does not have the medical expertise to provide an opinion regarding the prostate cancer etiology. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Thus, the Veteran's assertions that there is a relationship between his claimed prostate cancer disability and his service, to include as secondary to radiation exposure, are not sufficient in this instance and are outweighed by other probative evidence of record. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection and the claims must be denied. REASONS FOR REMAND The Board finds that more development is necessary prior to final adjudication of the claims remaining on appeal. Regarding the Veteran's claims for entitlement to service connection for kidney disease, hypothyroidism, erectile dysfunction, a distended or weakened bladder, cytomegalovirus and rheumatoid arthritis, the Board notes that the Veteran contends that these disabilities are the result of in-service radiation exposure as noted by his contentions in his December 2019 substantive appeal. As noted above, the Board has already conceded that the Veteran had likely radiation exposure. As a result, the question remains if this caused the present disabilities. The Veteran may still benefit from the special development procedures provided in 38 C.F.R. § 3.311 if having had a radiogenic disease and claimed exposure to ionizing radiation in service. Kidney disease, hypothyroidism, erectile dysfunction, a distended or weakened bladder, cytomegalovirus and rheumatoid arthritis are not any of the specific "radiogenic diseases" listed under 38 C.F.R. § 3.311 (b) (2). However, he has provided evidence otherwise that his claimed conditions may be "radiogenic diseases," and so the development procedures of section 3.311 still apply. See 38 C.F.R. § 3.311 (b) (4). As noted above, the procedure under section 3.311 is to forward the claim to the VA Under Secretary for Benefits for further consideration, who may request an advisory medical opinion from the Under Secretary for Health. In forming a final opinion whether a veteran's disease resulted from ionizing radiation exposure, the Under Secretary for Benefits may consider: the probable dose; the veteran's circumstances at time of in-service exposure; time-lapse between exposure and onset of disease, relative sensitivity of involved tissue to induction; and the extent of exposure to carcinogens outside of service. See 38 C.F.R. § 3.311 (e). As reflected above, development for a claim for service connection for prostate cancer based on radiation exposure was conducted as a September 2013 opinion was obtained from the Under Secretary for Health, from the Director, Post 9-11 Era Environmental Health Program which indicated that it was unlikely that the Veteran's prostate cancer could be attributed to ionizing radiation in service. Subsequently, in a September 2013 advisory opinion, the VA Director, Compensation Service opined that there was no reasonable possibility that the Veteran's prostate cancer resulted from radiation exposure in service. The Board notes that while the development for claims based on radiation exposure was conducted, this development specifically only addressed the claimed disability of residuals of prostate cancer which is addressed above. However, the Board finds that development is still required to specifically address the Veteran's current claims for service connection for kidney disease, hypothyroidism, erectile dysfunction, a distended or weakened bladder, cytomegalovirus and rheumatoid arthritis. Accordingly, the Board finds that a remand is required to develop the Veteran's claims pursuant to the provisions of 38 C.F.R. § 3.311. Additionally, regarding the Veteran's claim for service connection for rheumatoid arthritis, the Board notes that VA is obligated to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A (d) (2012). The threshold for finding a link between current disability and disease or injury in service is low. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran's service treatment records reflect that the Veteran presented with right leg pain and low back pain on multiple occasions. Notably, the Veteran has yet to undergo a specific VA examination in conjunction with his claimed rheumatoid arthritis disability. An examination or opinion is necessary to make a decision on a claim if the evidence of record contains competent evidence that the claimant has a current disability, and indicates that the disability or symptoms may be associated with the claimant's active military history, but does not contain sufficient medical evidence to make a decision on the claim. See 38 U.S.C. § 5103A (d) (2); 38 C.F.R. § 3.159(c) (4). Accordingly, the Board finds that he should be scheduled for a VA examination and opinion to determine whether the Veteran has a current rheumatoid arthritis disability that is related to service. The matters are REMANDED for the following action: 1. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for the disabilities on appeal. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. 2. The AMC/RO should develop the Veteran's claims pursuant to the provisions of 38 C.F.R. § 3.311. Specifically, based upon the VA Under Secretary for Health's dose estimates, the Under Secretary for Benefits and Under Secretary for Health should provide opinions as to whether it is at least as likely as not that the Veteran's kidney disease, hypothyroidism, erectile dysfunction, a distended or weakened bladder, cytomegalovirus and rheumatoid arthritis were caused by ionizing radiation exposure during service. In forming the opinions requested above, the Under Secretary for Benefits and Under Secretary for Health should be advised that the Board concedes the Veteran had radiation exposure as he was a participant of post-Operation REDWING and Operation HARDTACK. 3. Schedule the Veteran for a VA examination to determine the etiology of the claimed rheumatoid arthritis disability. Based on a review of the record and an examination of the Veteran, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran has a current rheumatoid arthritis disability that is related to any incident of the Veteran's service. Adequate reasons and bases for any opinion rendered must be provided. All studies deemed appropriate in the medical opinion of the examiner should be performed, and all the findings should be set forth in detail. The claims file should be made available to the examiner, who should review the entire claims folder in conjunction with this examination. 4. Thereafter, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James A. DeFrank, 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.