Citation Nr: 21041067 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 17-59 497 DATE: July 8, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. REMANDED Entitlement to service connection for a respiratory disability (claimed as pneumonia, asthma, and chronic bronchitis) is remanded. Entitlement to service connection for status post-lobectomy residuals is remanded. Entitlement to service connection for a sinus condition is remanded. Entitlement to service connection, to include on a secondary basis, for corneal ulcers is remanded. Entitlement to service connection, to include on a secondary basis, for right shoulder disability is remanded. Entitlement to service connection, to include on a secondary basis, for cervical spine disability is remanded. Entitlement to service connection, to include on a secondary basis, for bilateral carpal tunnel syndrome (CTS) is remanded. Entitlement to service connection, to include on a secondary basis, for bilateral ankle disability is remanded. Entitlement to service connection, to include on a secondary basis, for bilateral foot disability is remanded. Entitlement to service connection, to include on a secondary basis, for right knee disability is remanded. Entitlement to service connection, to include on a secondary basis, for left knee disability is remanded. Entitlement to service connection, to include on a secondary basis, for gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection, to include on a secondary basis, for erectile dysfunction is remanded. Entitlement to service connection, to include on a secondary basis, for testosterone deficiency is remanded. FINDING OF FACT The Veteran does not have a bilateral hearing loss disability for VA purposes. CONCLUSION OF LAW The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.385. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1987 to February 1990, and from May 1993 to July 1993. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2017 rating decision by a Department of Veterans Affairs Regional Office (RO). In October 2020, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. Lastly, the Board observes that additional evidence has been added to the claims file following the last adjudication by the AOJ in the September 2017 statement of the case (SOC), including private treatment records and private medical opinions. However, as the Veteran's substantive appeal was received in November 2017, which is after February 2, 2013, an automatic waiver of evidence submitted by the claimant or his representative is presumed. Additionally, the submitted evidence is not relevant to the issue decided below. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Bilateral Hearing Loss The Veteran seeks entitlement to service connection for bilateral hearing loss. His service treatment records (STRs) include a March 1987 enlistment examination noting normal ears and he denied any hearing loss. The following audiometric testing results were noted: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 5 0 LEFT 10 0 0 0 0 An October 1989 audiological evaluation noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 0 0 LEFT 5 0 0 0 0 Shortly before his separation from his first period of service, a January 1990 audiological evaluation noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 10 0 0 0 0 LEFT 5 0 0 0 0 During the period on appeal, the Veteran underwent a VA hearing loss examination in April 2017. The examiner noted the following audiometric testing results: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 5 10 LEFT 15 5 10 0 5 Speech recognition scores were 100 percent for the right ear and 96 percent for the left ear. He was diagnosed with normal hearing bilaterally. In his July 2017 notice of disagreement (NOD), the Veteran asserted that a March 1993 Report of Medical History "shows and acknowledges a hearing loss which was also tested at the Meps Center in Boston, Ma." At an October 2020 Board hearing, the Veteran testified that he believed he had hearing loss, and that he had a hard time hearing conversations and the TV. He further testified that he first noticed hearing loss years after service. With respect to hearing loss, VA has specifically defined what is meant by a "disability" for the purposes of service connection: "[I]mpaired 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 Test are less than 94 percent." 38 C.F.R. § 3.385. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). Service connection requires evidence that establishes that the Veteran currently has the claimed disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the absence of evidence showing that the Veteran's hearing loss rises to the level of being a disability as defined under 38 C.F.R. § 3.385, the Veteran's claim for service connection for bilateral hearing loss disability must be denied. Although the Veteran is certainly competent to report his observations as to his own senses (i.e., loss of hearing acuity), he is not competent to provide the opinion that his level of hearing difficulty rises to such severity to as be considered a hearing loss disability. The Board also recognizes that the Veteran reported that his May 1993 separation examination documented a hearing loss disability as indicated on his Report of Medical History. However, the claims file does not include his complete separation examination, including the Report of Medical History. In any event, even if the record did contain this record, it would not evidence a current hearing loss disability for VA purposes. Importantly, the Veteran does not assert that the April 2017 VA examination was inadequate, that the audiometric data was incorrect, or that his hearing had worsened since that examination. Therefore, remanding this matter solely to obtain a May 1993 record would serve no useful purpose as such would not change the outcome of the Board's conclusion. To reiterate, in order for hearing loss to be considered a disability for VA purposes, hearing impairment must, by regulation, satisfy a minimum threshold level of impairment. That degree of impairment is determined through application of specific audiometric tests prescribed by the regulations. Under the circumstances, the Veteran's assertions regarding hearing difficulty are not sufficient to establish a hearing loss disability, and are significantly less probative than the audiometric data obtained from audiometric testing during the period on appeal. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (although it is error to categorically reject a non-expert opinion as to etiology, or nexus, not all questions of nexus are subject to non-expert opinion; whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case). Based on current audiometric testing results, the Board concludes that the Veteran does not have disabling hearing loss in either ear for VA purposes. For that reason, he is not entitled to service connection for bilateral hearing loss, and his claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). REASONS FOR REMAND Initially, as noted above, the Veteran has referenced a May 1993 Report of Medical History that is not a part of the record. Instead, the record only contains one page of the May 1993 separation examination. Accordingly, efforts should be made to obtain the Veteran's complete STRs. 2-3. Respiratory Condition and Status Lobectomy Residuals The Veteran seeks entitlement to service connection for a respiratory/lung condition. In this regard, the Veteran asserts that he sustained respiratory illnesses during service that caused "severe scarring of the lungs which eventually required me to undergo a lobectomy of the entire lower lobe of my right lung." He additionally asserts that he developed a lung and/or respiratory condition due to breathing burning jet fuel (JP-4) fumes. See July 2017 NOD. At an October 2020 Board hearing, the Veteran testified that he was constantly exposed to fumes including jet fuel, cleaning chemicals and epoxy as part of his military occupational specialty (MOS) working on the flight line and repairing aircraft. In this regard, the Board notes that during his first period of service, his MOS was avionic systems specialist. See DA Form DD 214. He further testified that he began to have breathing problems following his separation from service, and that it was a slow progression over approximately 20 years until his lobectomy. In the 1990s, he reported being sick all the time with chronic bronchitis and pneumonia. The medical evidence of record includes a December 1997 private medical record showing the Veteran was assessed with asthmatic problems, and that a prior March 1996 spirometry test was noted to reveal mild obstructive lung disease. In April 2009, the Veteran was assessed with reactive airway disease. See Private Treatment Records Received March 2017. In October 2010, the Veteran was treated for bronchitis and asthma. He was treated for pneumonia in June 2011. See Private Treatment Records Received March 2017. A July 2011 private medical record noted the Veteran's mother reported he had developed respiratory problems, including asthma, at the age of 20. An August 2011 discharge summary noted a diagnosis for cystic lung disease, asthma and subcutaneous emphysema. The Veteran underwent a right lower lobectomy. A history of recurrent upper respiratory infections and exacerbations of asthma requiring hospital admission was noted. Another August 2011 medical record noted a history of recurrent respiratory infections over the past 10 years, which had progressively worsened the past 2 years. The Veteran was noted to have been on prolonged antibiotics. See Private Treatment Records Received March 2017. A February 2018 private medical record noted the Veteran had been exposed to jet fuel twice a day during service while working on F16s. Jet fuel was noted as having been blown on the Veteran 16 hours a day. The physician, Dr. Miner, noted that a review of medical literature made it clear to him that kerosene jet fuel exposure might be a significant cause of his persistent respiratory problems. Lastly, in an August 2020 letter, Dr. Miner noted the Veteran had been a patient for over 26 years. It was also noted that the Veteran had reported constant exposure to jet fuel and jet fuel propellants during service. Dr. Miner further noted a lengthy history of asthma and asthma induced respiratory illnesses, and that he had undergone treatment for a right middle lobe abscess. Noted treatment included being placed on antibiotics, including levofloxacin and ciprofloxacin, and corticosteroids numerous times. Dr. Miner found that the respiratory conditions were directly related to exposure to airborne toxins during service. The Board finds both the February 2018 and August 2020 opinions from Dr. Miner inadequate to adjudicate this issue on appeal. Specifically, Dr. Miner did not provide any rationale in support of the findings rendered. Additionally, to date, the Veteran has not been provided with a VA examination. In consideration of his MOS, lay statements linking his diagnosed respiratory/lung conditions to in-service environmental exposures, and a private treatment record noting the Veteran developed an asthmatic condition during his first period of active duty service, the Board finds that a VA examination is necessary to determine the nature etiology of his diagnosed respiratory/lung conditions. 4. Sinus Condition The Veteran seeks entitlement to service connection for a sinus condition. Specifically, the Veteran asserts that he developed a sinus condition due to exposure to jet fuel during service. See February 2018 Private Medical Record. Alternatively, the Veteran asserts that he developed a sinus condition secondary to constant respiratory illnesses which caused his body to be under constant infection. See October 2020 Board Hearing Transcript. The evidence of record includes a July 1997 private medical record showing the Veteran reported that he began developing sinus infections when he was 17 years old. He also reported that he did not have any sinus infections the two years he was in service. A December 1997 private medical record noted the Veteran had chronic nasal problems, and a past history for septoplasty and turbinectomy with marked improvement. The Veteran was treated for allergic rhinitis in July 2010. In February 2011, he reported symptoms of sinus facial pressure, nasal pressure and wheezing. He was assessed with sinusitis. See Private Treatment Records Received March 2017. A February 2018 private medical record noted the Veteran had been exposed to jet fuel twice a day during service while working on F16s, with jet fuel noted as blown on the Veteran 16 hours a day. Since that time, he reported recurrent sinusitis. The physician, Dr. Miner, noted that a review of medical literature made it clear to him that kerosene jet fuel exposure might be a significant cause of the Veteran's persistent sinus problems. The Board finds the February 2018 medical opinion from Dr. Miner to be inadequate to adjudicate this issue on appeal as it does not contain any rationale in support of the findings rendered. Accordingly, in order to properly adjudicate this issue on appeal, a VA examination is necessary to determine the nature etiology of his diagnosed sinus conditions. 5-8. Corneal Ulcers, GERD, Erectile Dysfunction and Testosterone Deficiency The Veteran seeks entitlement to service connection for corneal ulcers, GERD, erectile dysfunction and testosterone deficiency, conditions for which the medical evidence does show diagnoses. With regard to his claim for corneal ulcers, the Veteran asserts that his body produced extra protein antibodies in his eyes due to respiratory infections, which caused corneal ulcers. With regard to his claim for GERD, he asserts that due to long-term antibiotic treatment for respiratory infections, his intestines and stomach became severely irritated resulting in GERD. With regard to the service connection claims for erectile dysfunction and testosterone deficiency, he asserts that the conditions are due to his respiratory infections which caused his endocrine system to break down and weaken. See July 2017 NOD. In this regard, a May 2015 private medical record noted the Veteran underwent septic shock following a lobectomy, and that due to the lobectomy, scarring of the lungs and chronic inflammation, "such probably stopped the stimulation of testosterone from his pituitary." Accordingly, these issues are intertwined with the service connection claim for a respiratory condition. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). As the claims should be considered together, it follows that, any Board action on these claims, at this juncture, would be premature. Hence, a remand of these matters is warranted, as well. 9-15. Right Knee, Left knee, Right Shoulder, Cervical Spine, Bilateral Ankle, Bilateral Foot, CTS The Veteran asserts entitlement to service connection for several musculoskeletal conditions, including right and left knee disability, and disabilities affecting his right shoulder, cervical spine, bilateral ankle and bilateral foot. He additionally asserts entitlement to service connection for CTS. With regard to these issues on appeal, the Veteran asserts they are secondary to medications used to treat his respiratory condition. See August 2020 Dr. Miner Letter and October 2020 Board Hearing Transcript. With regard to his bilateral knee disability, he also asserts that those conditions are directly related to service. With regard to his right knee disability, the record shows that he injured that knee in March 1992, during a period he was not on active duty service. The Veteran asserts that he aggravated his right knee during his second period of active duty service in 1993. See July 2017 NOD. The Veteran's May 1993 enlistment examination noted a knee injury in March 1992 and that he had undergone right knee arthroscopic surgery that same month. As a result of the surgery, he was noted to have developed a hemal process and required aspiration of the joint on 3 different occasions. Thereafter, he was noted to have undergone extensive physio-therapy to regain muscle strength of quadriceps, hamstrings and his calf. Following treatment ending in September 1992, he was noted to be asymptomatic. A June 1993 STR shows the Veteran complained of bilateral knee pain and right knee symptoms of grinding and popping. He also complained of left knee lateral pain. No gross swelling or locking was found. He was assessed with chronic knee pain. A prior history of plica resection was noted. A July 1993 Entrance Physical Standards Board Proceedings document noted the Veteran could not train due to knee pain. No instability or effusion was found. An X-ray study was negative. The Veteran was diagnosed with status post arthroscopic plica resection with chronic pain and it was recommended he be separated due to not meeting the medical fitness standards. The Veteran underwent a VA knee examination in May 2017. The examiner noted a diagnosis for right knee strain and bilateral degenerative arthritis. It was noted the Veteran underwent right knee surgery in March 1992 related to a workman compensation claim. The examiner noted the Mach 1993 enlistment examination which noted the March 1992 knee injury and that Veteran had undergone surgery and physio-therapy, and that he became symptom free since he returned to work in September 1992. It was further noted that in June 1993, during basic training, the Veteran complained of right knee grinding and popping, and left knee lateral pain. The examiner also noted the July 1993 Entrance Physical Standards Board Proceedings document. In addition, it was noted that there was no evidence of any knee evaluation or treatment from 1993 to 2017. Based on the above evidence, the examiner opined that the right knee disability, "clearly and unmistakably" existed prior to the Veteran's second period of service, and "was not aggravated beyond its natural progression by an in-service event, injury or illness." In support of this opinion, the examiner noted no evidence of aggravation. Specifically, the examiner noted no treatment at all between 1992 and 2017. Accordingly, the examiner concluded that any current knee issues were "at least as likely as not (>50% probability) the result of aging, deconditioning, and occupational history of physical labor." In an August 2020 letter, Dr. Miner noted the Veteran had been a patient for over 26 years. It was also noted the Veteran had reported constant exposure to jet fuel and jet fuel propellants during service. Dr. Miner further noted a lengthy history of asthma and asthma induced respiratory illnesses, and chronic frontal and maxillary sinusitis, and that he had undergone treatment for a right middle lobe abscess. Numerous antibiotics treatments, including levofloxacin and ciprofloxacin, and corticosteroids, was noted. With regard to the antibiotics, levofloxacin and ciprofloxacin were noted to be associated with diffuse thickening and loss of fibrillar echotexture and multiple partial tendon tears. Related tendon ruptures were noted to occur spontaneously and induced non-traumatically. With regard to the Veteran, Dr. Miner noted he had experienced such non-traumatic multiple muscular injuries including bilateral shoulder, knee and achilles tears. Each tear was found to be partially, if not completely, related to the combination of antibiotic and corticosteroid treatments. As such, Dr. Miner found that the respiratory and musculoskeletal conditions were directly related to exposure to airborne toxins during service. Lastly, in June 2020 letter, Dr. Keigwin noted that the Veteran had a history of prednisone usage, and that such was "a possible or plausible cause of his shoulder conditions." With regard to the May 2017 VA knee examination, the August 2020 letter from Dr. Miner, and the June 2020 letter from Dr. Keigwin, the Board finds they are inadequate to adjudicate these issues on appeal. Turning to the May 2017 VA knee examination, the examiner only provided a medical opinion that addressed the right knee despite STRs showing additional complaints for left knee pain during service. Accordingly, a VA examination addressing whether the left knee disability is etiologically related to service is needed to properly adjudicate this issue on appeal. With regard to the Veteran's claim that all of the above conditions are due to antibiotic and corticosteroid treatments, the Board finds the August 2020 letter from Dr. Miner inadequate. In this regard, Dr. Miner does not cite any supporting medical literature, or any evidence in support of a finding that antibiotics were noted to be associated with diffuse thickening and loss of fibrillar echotexture and multiple partial tendon tears. Therefore, it is entirely unclear to the Board what this finding is based upon, and the Board cannot attempt to interpret or extrapolate the rationale employed by the examiner on its own. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (finding that the Board is prohibited from exercising its own independent judgment to resolve medical questions). Finally, the Board finds Dr. Keigwin's June 2020 opinion letter inadequate as it is speculatory in nature. Accordingly, the service connection claim for left knee disability is remanded to obtain a VA examination that addresses the direct service connection claim on appeal. The remainder of the issues are intertwined with the service connection claim for respiratory/lung condition. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. Request the Veteran's complete service treatment records, to include from his second period of service in 1993. If the requested service treatment records are unavailable, issue a formal finding of unavailability and notify the Veteran and allow him the opportunity to submit any medical records in his possession. 3. After the above development has been completed, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed respiratory/lung condition, (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner should provide the following opinions: Is it at least as likely as not (50 percent or greater probability) that any diagnosed respiratory/lung condition, to include asthma, mild obstructive lung disease, bronchitis, pneumonia, cystic lung disease and subcutaneous emphysema, is etiologically related to his period of service? The examiner is asked to consider the Veteran's lay statements regarding exposure to toxins during service including JP-4 jet fuel, cleaning chemicals and epoxy, and Dr. Miner's August 2020 letter opining that he developed respiratory conditions due to exposure to airborne toxins during service. 4. After the development in #1 & #2 has been completed, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed sinus condition, (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner should provide the following opinions: Is it at least as likely as not (50 percent or greater probability) that any diagnosed sinus condition, to include sinusitis and allergic rhinitis, is etiologically related to his period of service? The examiner is asked to consider the Veteran's lay statements regarding exposure to toxins during service including JP-4 jet fuel, cleaning chemicals and epoxy, and Dr. Miner's August 2020 letter opining that he developed sinus conditions due to exposure to airborne toxins during service. 5. After the development in #1 & #2 has been completed, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed left knee disability (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner should provide the following opinions: Is it at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed left knee disability is etiologically related to his period of service? The examiner is asked to consider STRs noting complaints of left knee pain in June 1993. 6. If, and only if, the AOJ determines that service connection for a respiratory/lung condition is warranted, then schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed corneal ulcers, GERD, erectile dysfunction and testosterone deficiency (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed corneal ulcers, GERD, erectile dysfunction and testosterone deficiency was caused by the Veteran's respiratory/lung disability, to include medications used to treat those conditions such as antibiotics? Please explain why or why not. With regard to erectile disfunction and testosterone deficiency, the examiner is asked to consider the May 2015 private medical record noting the Veteran underwent septic shock following his lobectomy and due to the lobectomy with scarring, and chronic inflammation, such probably stopped the stimulation of testosterone form his pituitary. (b) Is it at least as likely as not (50 percent or greater probability) that any diagnosed corneal ulcers, GERD, erectile dysfunction and testosterone deficiency was aggravated by the Veteran's respiratory/lung disability, to include medications used to treat those conditions such as antibiotics? Please explain why or why not. If the examiner finds that the disability was aggravated by the service-connected disability, the examiner must identify the baseline level of the disability that existed before aggravation by the service-connected disability occurred. With regard to erectile disfunction and testosterone deficiency, the examiner is asked to consider the May 2015 private medical record noting the Veteran underwent septic shock following his lobectomy and due to the lobectomy with scarring, and chronic inflammation, such probably stopped the stimulation of testosterone form his pituitary. 7. If, and only if, the AOJ determines that service connection for a respiratory/lung condition is warranted, then schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed bilateral knee, cervical spine, right shoulder, bilateral ankle, bilateral foot and bilateral carpal tunnel syndrome condition (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that any diagnosed bilateral knee, cervical spine, right shoulder, bilateral ankle, bilateral foot and bilateral carpal tunnel syndrome condition was caused by his respiratory condition, to include antibiotics and medications used to treat the condition, including levofloxacin and ciprofloxacin, and corticosteroids? Please explain why or why not. The examiner is asked to consider the conclusions reached in Dr. Miner's August 2020 letter in which use of antibiotics to treat repeated respiratory infections, including levofloxacin and ciprofloxacin, were noted to be associated with diffuse thickening and loss of fibrillar echotexture and multiple partial tendon tears. The examiner is further asked to consider Dr. Miner's conclusion that each tear "was partially, if not completely, related to the combination of antibiotic and corticosteroid treatments." (b) Is it at least as likely as not (50 percent or greater probability) that any diagnosed bilateral knee, cervical spine, right shoulder, bilateral ankle, bilateral foot and bilateral carpal tunnel syndrome condition was aggravated by his respiratory condition, to include antibiotics and medications used to treat the condition, including levofloxacin and ciprofloxacin, and corticosteroids? Please explain why or why not. The examiner is asked to consider the conclusions reached in Dr. Miner's August 2020 letter in which use of antibiotics to treat repeated respiratory infections, including levofloxacin and ciprofloxacin, were noted to be associated with diffuse thickening and loss of fibrillar echotexture and multiple partial tendon tears. The examiner is further asked to consider Dr. Miner's conclusion that each tear "was partially, if not completely, related to the combination of antibiotic and corticosteroid treatments." (Continued on the next page) 8. Then, the AOJ must readjudicate the remaining issues on appeal. If the benefits sought remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Lamb, 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.