Citation Nr: 21041219 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 18-12 806 DATE: July 8, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy of the sciatic nerve is dismissed. Entitlement to an initial rating in excess of 10 percent for left lower extremity peripheral neuropathy of the sciatic nerve is dismissed. Entitlement to an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy of the femoral nerve is dismissed. Entitlement to an initial rating in excess of 10 percent for left lower extremity peripheral neuropathy of the femoral nerve is dismissed. Entitlement to an initial compensable rating for partial right nephrectomy for kidney cancer is dismissed. Entitlement to service connection for a right ankle disorder is dismissed. Entitlement to service connection for bilateral hearing loss is dismissed. Entitlement to service connection for tinnitus is dismissed. Entitlement to service connection for a sleep disorder, to include obstructive sleep apnea, is dismissed. Entitlement to service connection for chronic fatigue is dismissed. Entitlement to service connection for right hand skin cancer is dismissed. Entitlement to a temporary total 100 percent evaluation based on surgery necessitating convalescence for kidney surgery is dismissed. New and material evidence having been received, the petition to reopen a claim of entitlement to service connection for coronary artery disease is granted; the claim is granted to that extent only. Entitlement to service connection for right upper extremity peripheral neuropathy is denied. Entitlement to service connection for left upper extremity peripheral neuropathy is denied. Entitlement to service connection for an acquired psychiatric disorder, namely posttraumatic stress disorder (PTSD) and depression, is granted. REMANDED Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for a cervical spine disorder is remanded. Entitlement to service connection for a right hip disorder is remanded. Entitlement to service connection for a left hip disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for hypertension, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for a cardiovascular disorder, to include as due to herbicide agent exposure, is remanded. Entitlement to service connection for cataracts, to include as secondary to service connected diabetes mellitus, is remanded. Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU) is remanded. FINDINGS OF FACT 1. At his April 6, 2021 Board hearing, the Veteran testified that he was withdrawing the issues of entitlement to increased initial ratings for right lower extremity peripheral neuropathy of the sciatic nerve, left lower extremity peripheral neuropathy of the sciatic nerve, right lower extremity peripheral neuropathy of the femoral nerve, left lower extremity peripheral neuropathy of the femoral nerve, and partial nephrectomy for kidney cancer; entitlement to service connection for a right ankle disorder, bilateral hearing loss, tinnitus, a sleep disorder, chronic fatigue, and right hand skin cancer; and entitlement to a temporary total 100 percent evaluation based on surgery necessitating convalescence for kidney surgery. 2. An unappealed May 2014 rating decision denied the claim of entitlement to service connection for coronary artery disease associated with herbicide exposure. 3. The evidence associated with the claims file subsequent to the May 2014 rating decision is not cumulative nor redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for coronary artery disease. 4. At no time during the pendency of the claim does the Veteran have a diagnosis of right upper extremity peripheral neuropathy and left upper extremity peripheral neuropathy, and the record does not contain a recent diagnosis of such disability prior to the Veteran's filing of a claim. 5. Resolving doubt in favor of the Veteran, his acquired psychiatric disorder is etiologically related to his active service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the issue of entitlement to an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy of the sciatic nerve have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 2. The criteria for withdrawal of the issue of entitlement to an initial rating in excess of 10 percent for left lower extremity peripheral neuropathy of the sciatic nerve have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 3. The criteria for withdrawal of the issue of entitlement to an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy of the femoral nerve have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 4. The criteria for withdrawal of the issue of entitlement to an initial rating in excess of 10 percent for left lower extremity peripheral neuropathy of the femoral nerve have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 5. The criteria for withdrawal of the issue of entitlement to an initial compensable rating for partial right nephrectomy for kidney cancer have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 6. The criteria for withdrawal of the issue of entitlement to service connection for a right ankle disorder have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 7. The criteria for withdrawal of the issue of entitlement to service connection for right upper extremity peripheral neuropathy have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 8. The criteria for withdrawal of the issue of entitlement to service connection for left upper extremity peripheral neuropathy have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 9. The criteria for withdrawal of the issue of entitlement to service connection for bilateral hearing loss have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 10. The criteria for withdrawal of the issue of entitlement to service connection for tinnitus have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 11. The criteria for withdrawal of the issue of entitlement to service connection for a sleep disorder, to include obstructive sleep apnea, have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 12. The criteria for withdrawal of the issue of entitlement to service connection for chronic fatigue have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 13. The criteria for withdrawal of entitlement to service connection for right hand skin cancer have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 14. The criteria for withdrawal of the issue of entitlement to a temporary total 100 percent evaluation based on surgery necessitating convalescence for kidney surgery have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.204. 15. The May 2014 rating decision denying the claim for service connection for a coronary artery disease associated with herbicide exposure is final and new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for coronary artery disease. 38 U.S.C. §§ 5108, 7104, 7105; 38 C.F.R. § 3.156. 16. The criteria for service connection for right upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 17. The criteria for service connection for left upper extremity peripheral neuropathy have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 18. The criteria for service connection for an acquired psychiatric disorder, namely PTSD and depression, have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from April 1968 to April 1972, to include service in the Republic of Vietnam. These matters come to the Board of Veterans' Appeals (Board) on appeal from August 2013, July 2017, and September 2017 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Cleveland, Ohio. The Veteran testified at a virtual video conference hearing before the undersigned Veterans Law Judge (VLJ) of the Board in April 2021. A transcript of the hearing has been associated with the claims file. Following the hearing, the record was held open for 60 days to allow VA to submit additional evidence and argument. Relevant to the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, such was originally adjudicated by the RO as claims for entitlement to service connection for PTSD. However, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that, in determining the scope of a claim, the Board must consider the claimant's description of the claim; symptoms described; and the information submitted or developed in support of the claim. In light of the Court's decision in Clemons, the Board has recharacterized the issue on appeal as entitlement to service connection for an acquired psychiatric disorder, to include PTSD and depression. Withdrawal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the Veteran or by his/her authorized representative. 38 C.F.R. § 20.204. At his April 2021 Board hearing, the Veteran indicated that he was withdrawing his claims for entitlement to increased initial ratings for right lower extremity peripheral neuropathy of the sciatic nerve, left lower extremity peripheral neuropathy of the sciatic nerve, right lower extremity peripheral neuropathy of the femoral nerve, left lower extremity peripheral neuropathy of the femoral nerve, and partial nephrectomy for kidney cancer; entitlement to service connection for a right ankle disorder, bilateral hearing loss, tinnitus, a sleep disorder, chronic fatigue, and right hand skin cancer; and entitlement to a temporary total 100 percent evaluation based on surgery necessitating convalescence for kidney surgery. The Board finds that the Veteran's withdrawal is explicit, unambiguous, and done with a full understanding of the consequences of such action. See DeLisio v. Shinseki, 25 Vet. App. 45, 57 (2011). As a result, no allegation of error of fact or law remains before the Board for consideration with regard to these issues. Accordingly, the Board does not have jurisdiction over these issues, and the claims for entitlement to increased initial ratings for right lower extremity peripheral neuropathy of the sciatic nerve, left lower extremity peripheral neuropathy of the sciatic nerve, right lower extremity peripheral neuropathy of the femoral nerve, left lower extremity peripheral neuropathy of the femoral nerve, and partial nephrectomy for kidney cancer; entitlement to service connection for a right ankle disorder, bilateral hearing loss, tinnitus, a sleep disorder, chronic fatigue, and right hand skin cancer; and entitlement to a temporary total 100 percent evaluation based on surgery necessitating convalescence for kidney surgery are dismissed. Claim to Reopen Coronary Artery Disease As a threshold matter, the Board must determine whether new and material evidence has been submitted to reopen a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001) (reopening after a prior unappealed RO denial) A rating decision becomes final when it has not been appealed within the prescribed time period and when no additional material evidence was received within a year of the decision; the decision is not subject to revision on the same factual basis. 38 U.S.C. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In order to reopen a claim, there must be added to the record "new and material evidence." 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can neither be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. The law provides that new and material evidence necessary to reopen previously and finally disallowed claims must be secured or presented since the time that the claims were finally disallowed on any basis, not only since the time the claims were last disallowed on the merits. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). 38 C.F.R. § 3.156(a), which defines new and material evidence, requires that evidence raise a reasonable possibility of substantiating the claim in order to be considered "new and material," and defines material evidence as evidence, that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. The Court has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's claim for service connection for coronary artery disease was denied in a May 2014 rating decision. Specifically, the rating decision indicates that the Veteran did not have a diagnosis of coronary artery disease. Evidence considered in this rating decision include post-service VA and private treatment records. The Veteran was notified of this decision in a May 2014 letter. There was no further communication regarding his claim of entitlement to service connection for coronary artery disease was received until March 2016, when VA received his petition to reopen such claim. Therefore, the May 2014 rating decision is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. However, in the instant case, such regulation is inapplicable as no relevant evidence pertaining to the Veteran's claim for service connection was received prior to the expiration of the appeal period stemming from May 2014 rating decision. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). Moreover, no additional service records (warranting reconsideration of the claim) have been received at any time. See 38 C.F.R. § 3.156(c). The Veteran filed the instant claim to reopen his claim for entitlement to service connection for coronary artery disease, which was received by VA in March 2016. The pertinent evidence that has been received since the May 2014 rating decision includes continuing post-service treatment records and Board hearing testimony. Presuming the credibility of the Veteran's sworn testimony before the Board, the Board finds that the evidence is new and material. In this regard, it has not been previously considered by VA and it raises a reasonable possibility of substantiating the claim of entitlement to service connection for coronary artery disease. The claim for service connection for coronary artery disease was previously denied because there was no evidence showing that the Veteran had a current diagnosis of coronary artery disease. However, post-service treatment records show the Veteran may have a diagnosis of coronary artery disease. See Private treatment record, January 20, 2014. Accordingly, reopening of the claim of entitlement to service connection for coronary artery disease is warranted. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995). VA has amended 38 C.F.R. § 3.310 to explicitly incorporate the holding in Allen, except that it will not concede aggravation unless a baseline for the claimed disability can be established with evidence created prior to any aggravation. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Right Upper Extremity and Left Upper Extremity Peripheral Neuropathy The Veteran seeks service connection for right upper extremity and left upper extremity peripheral neuropathy, as secondary to his service connected diabetes mellitus. See e.g. Board hearing transcript, April 6, 2021. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that §§ 1110 and 1131's requirement of the existence of a present disability for VA compensation purposes cannot be considered arbitrary); see also McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA compensation is filed or during the pendency of that claim). Consequently, the evidence of record must show that the Veteran currently has the disability for which benefits are being claimed. Service treatment records and post service treatment records are negative for complaints of, treatment for, or diagnosis of right upper extremity and left upper extremity peripheral neuropathy. No post-service clinical records have been submitted showing such diagnoses. In consideration of evidence of record, the Board finds no current diagnosis of right upper extremity and left upper extremity peripheral neuropathy is present. Specifically, the Board notes July 2013 and August 2017 VA examination reports indicating his right and left upper extremities were normal with respect to peripheral neuropathy. See VA examination reports, July 29, 2013 and August 10, 2017. The Board notes a current disability is always required in order to establish service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). With regard to the claimed headaches there is not sufficient evidence to show that the Veteran has had RUE and LUE peripheral neuropathy during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board acknowledges the Court's holding in Saunders but does not find a basis for determining that there is functional impairment related to a diagnosis of right upper extremity and left upper extremity peripheral neuropathy. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In addition, the Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). In summary, the controlling question in this case is answered in the negative. In the absence of proof of a present disability (and, if so, of a nexus between that disability and service), there can be no valid claim for service connection. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the veteran has it; without this minimum level of proof, there can be no valid claim). Therefore, as the evidence of record shows that the Veteran does not have right upper extremity and left upper extremity peripheral neuropathy, the Board concludes that service connection is not warranted, and no further discussion of the remaining elements is necessary. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."); see also Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006) (finding that the absence of any one element will result in denial of service connection). Accordingly, the Board finds that the preponderance of the evidence is against the claims and the claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Acquired Psychiatric Disorder The Veteran seeks service connection for an acquired psychiatric disorder, to include PTSD and depression. Specifically, the Veteran asserts that his symptoms began during active service as a result of abuse during basic training, and a motor vehicle accident that occurred in 1969. See e.g. Board hearing transcript, April 6, 2021; see also Correspondence, April 3, 2020; see also Notice of Disagreement, November 28, 2013. Additionally, the Veteran asserts that he experienced trauma while serving in the Republic of Vietnam. See e.g. VA Form 21-4138 Statement in Support of Claim, December 20, 2020. Turning to the evidence, service treatment records are unremarkable for complaints of, treatment for, or diagnoses of any acquired psychiatric disorder. The Board notes that the Veteran was treated for a left knee injury following a motor vehicle accident in March 1969. See Service treatment record, April 7, 1969. Additionally, the Veteran's military personnel records show the Veteran had service in the Republic of Vietnam from January 23, 1971 to April 5, 1971. Turning to the question of whether there is an etiological relationship between the Veteran's acquired psychiatric disorder and his service, the Board notes that the record contains contradicting opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board will consider each of these opinions below. At a July 2013 VA examination, the examiner opined the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) criteria, and the Veteran did not have a mental disorder that conformed with the DSM-IV criteria. The examiner found the Veteran did not have a mental disorder. The examiner noted that there were no mental health treatment records in service nor any complaints of mental health symptoms at his separation physical. The examiner opined that the Veteran did not have PTSD or other mental condition diagnosed, and that the current mood concerns, if present, would more likely be related to the present worrisome declines in his physical health and pain. Therefore, the examiner found the current mood concerns are not likely at all to be related to in-service stressors, especially given the overall timeframe. The Board finds this opinion highly probative as the examiner reviewed the claims file, interviewed the Veteran, and provided an opinion supported by a clear rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). A February 2017 PTSD Disability Benefits Questionnaire (DBQ) report was completed by Dr. F.P., the Veteran's treating VA psychologist, and noted diagnoses of PTSD and depression. The psychiatrist opined that due to a motor vehicle accident during his service, the Veteran experienced heightened symptoms of anxiety while driving, including increased sweating and road rage. Additionally. Dr. F.P. noted the Veteran lost track of place and time during drives and had to reply on the global positing system talking to him. The psychiatrist also opined that the Veteran's psychiatric conditions were based on his military service. The Board finds this opinion highly probative as the examiner reviewed the claims file, interviewed the Veteran, and provided an opinion supported by a clear rationale. Id. At a January 2018 VA examination, the VA examiner opined that the Veteran did not have a mental disorder that conformed with Diagnostic and Statistical Manual (Fifth Edition) (DSM-V) criteria. The examiner noted that the Veteran's service treatment records did not reflect complaints of mental health symptoms. With regard to the February 2017 opinion, the January 2018 VA examiner noted that Dr. F.P. deferred to the diagnosis to data found in the mental health records and did not mention the former VA examination records noting over-reported psychiatric symptoms. The examiner found that the Veteran over-reported his psychiatric symptoms and functional impairments and therefore that the self-report was deemed unreliable, and it was therefore, not possible to posit a reasonably accurate estimate using the DBQ checkboxes in this context, although each area was addressed during the interview. The Board finds this opinion highly probative as the examiner reviewed the claims file, interviewed the Veteran, and provided an opinion supported by a clear rationale. Id. An August 2018 psychiatric opinion by Dr. F.P., was submitted that noted a diagnosis of PTSD and opined that his PTSD was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. In that regard, the psychologist noted that the Veteran's PTSD related back to a motor vehicle accident that occurred in 1969 as well as stressful combat experiences while service in the Republic of Vietnam. The psychologist also noted that the Veteran challenged the authority of the Marines several times during training, which often resulted in traumatic experiences for the Veteran and that the Veteran was beat, hung upside down in a locker with ammonia splashing around him, and allowed to vomit while hanging upside down. The psychologist noted the Veteran's motor vehicle accident was reference in a medical note in his military records, prior to his service in the Republic of Vietnam. The Board finds this opinion highly probative as the examiner reviewed the claims file, interviewed the Veteran, and provided an opinion supported by a clear rationale. Id. An October 2018 private opinion by Dr. M.H., a private counselor, was submitted and noted the Veteran's reports of in-service events that included being beaten during basic training. The provider also noted the Veteran was treated and seen on a weekly basis for individual counseling. The provider opined that, given the Veteran's descriptions of the traumatic event in service and the subsequent history of symptoms of PTSD, his claimed condition was at least as likely as not incurred by the claimed in-service incident that occurred in basic training and exacerbated by his combat experiences. The Board finds this opinion highly probative as the examiner reviewed the claims file, interviewed the Veteran, and provided an opinion supported by a clear rationale. Id. In sum, the Veteran has competently and credibly reported symptoms of an acquired psychiatric disorder that began during active service and have continued since. The Veteran has current diagnoses of an acquired psychiatric disorder, namely PTSD and depression and that probative private opinions from August 2018 and October 2018 indicating the Veteran's acquired psychiatric disorder is at least as likely as not related to his active service. Moreover, there is no sufficient basis for the Board to reject this supportive opinions and to further develop the claim. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). Accordingly, the Board finds that the preponderance of the evidence is for the claim and entitlement to service connection for an acquired psychiatric disorder, namely PTSD and depression, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Service Connection Lumbar Spine, Cervical Spine, Right Hip, Left Hip, Right Knee, Left Knee, and Left Ankle Disorders The Veteran seeks entitlement to service connection for lumbar spine, cervical spine, right hip, left hip, right knee, left knee, and left ankle disorders as a result of his active service. Specifically, he contends that such disorders were as a result of a motor vehicle accident that occurred during active service. See e.g. Board hearing transcript, April 6, 2021; see also Correspondence, April 3, 2020; see also Notice of Disagreement, November 28, 2013. Additionally, the Veteran asserts that he his disabilities are as a result of his service in the Republic of Vietnam. See e.g. VA Form 21-4138 Statement in Support of Claim, December 20, 2020. The Veteran was afforded VA examinations for his claims in July 2013. At that time, the examiner opined that his lumbar spine, cervical spine, right hip, left hip, right knee, left knee, and left ankle disorders were less likely than not as result of his active service. With regard to his lumbar spine, the July 2013 examiner opined that it was less likely as not that his current back condition was related to military service because the findings and history on examination for the low back were not consistent with the lumbar strain condition treated in service. Additionally, there lacked evidence of chronic ongoing complaint back to date of his active service. With regard to his cervical spine, the July 2013 examiner found there was no diagnosis of a cervical spine condition. The examiner noted that the Veteran described a cervical spine fusion that was not treated in service, his history was not consistent with an injury associated with military service, and his service treatment records did not report a cervical spine condition that was treated in service. With regard to his right and left hips, the July 2013 examiner found that the Veteran did not have a hip pathology, and his history was consistent with an etiology associated with the lumbar spine rather than a hip condition. Therefore, the examiner found a hip examination was not indicated. With regard to his right knee, the July 2013 examiner found that it was less likely as not that his right knee condition related to military service because the Veteran was not treated in service for a right knee condition, and there lacked evidence of a chronic ongoing condition that dated back to his active service. With regard to his left knee, the July 2013 examiner found that it was less likely as not that his left knee condition was related to military service because his service treatment records demonstrated a left knee strain in 1969 without further troubles; and the history and findings on examination were not consistent with a left knee strain that occurred over 40 years prior. With regard to his left ankle, the July 2013 examiner found that it was less likely as not that his left ankle condition was as a result of his military service because there lacked evidence of a chronic ongoing condition that dated back to active service. However, the examiner did not consider the Veteran's reports that his symptoms began during service. See, e.g., Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). A September 2013 from Dr. J.P., a private physician, noted that the Veteran had a history of a motor vehicle accident that occurred in March 1969 during active service, and that he had complained of neck, hip, knee, and back pain due to injuries sustained at that time. Therefore, this physician opined it was at least as likely as not that his ailment may have been triggered due to the injuries sustained and subsequent effect of such motor vehicle accident. However, the speculative terminology used by this physician does not provide a sufficient basis for an award of service connection. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (a doctor's statement framed in terms such as "could have been" is not probative); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) ("may or may not" language by a physician is too speculative). The Board notes that a May 2021 addendum opinion was submitted from this physician, who reiterated the prior opinion and continued to employ the speculative language. Therefore, the Board finds that a remand is warranted to obtain additional VA opinions to determine that nature and etiology of the claimed lumbar spine, cervical spine, right hip, left hip, right knee, and left knee disorders. When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Service Connection Hypertension and Cardiovascular Disorder The Veteran asserts that his hypertension and cardiovascular disorder are as due to his active service, to include herbicide agent exposure sustained during his period of service in the Republic of Vietnam. See e.g. Board hearing transcript, April 6, 2021. As discussed above, the Board notes the Veteran has verified service in the Republic of Vietnam, and therefore, his exposure to herbicide agents is conceded. In light of the foregoing, the Board concludes that the appellant should be afforded a VA examination to determine the nature and etiology of the claimed hypertension and cardiovascular disorder. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). 3. Service Connection Cataracts The Veteran seeks entitlement to service connection for cataracts as secondary to his service connected diabetes mellitus. See e.g. Board hearing transcript, April 6, 2021. Additionally, the Veteran asserts that he his disabilities are as a result of his service in the Republic of Vietnam. See e.g. VA Form 21-4138 Statement in Support of Claim, December 20, 2020. The Veteran was afforded a VA examination for his claim in June 2013. At that time, the examiner opined that his cataracts were not secondary to his service-connected diabetes mellitus because his cataracts were age appropriate and not caused by or related to his service connected diabetes mellitus. The Board finds this opinion to be inadequate to decide the claim as the examiner failed to provide a rationale for the conclusions reached. Nieves-Rodriguez v. Peake, supra. In addition, an opinion as to direct service connection and an opinion as to secondary service connection on an aggravation basis The Board notes the Veteran reported eye trouble at his March 1968 entrance physical into active service. Therefore, the Board finds that a remand is warranted to obtain an additional VA opinion to determine that nature and etiology of the claimed cataracts. See Barr v. Nicholson, supra. 4. Entitlement to a TDIU The Veteran contends that he is unemployable as a result of his PTSD, kidney cancer, and back. See VA Form 21-8940 Veterans Application for Increased Compensation Based on Unemployability, January 2, 2020. Thus, under the circumstances of this case, the Board finds the issue of entitlement to a TDIU are inextricably intertwined with the issue of entitlement to service connection for a lumbar spine disorder is being remanded herein. See Parker v. Brown, 7 Vet. App. 116 (1994) and Harris v. Derwinski, 1 Vet. App. 180, 183 (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). Hence, any Board action on the claim for a TDIU would be premature at this juncture. The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, obtain an etiology opinion as to the Veteran's claimed lumbar spine, cervical spine, right hip, left hip, right knee, left knee, and left ankle disorders from an appropriate medical professional. The record must be made available to the examiner. The need for an additional examination of the Veteran is left to the discretion of the examiner. The examiner should respond to the following questions: (A) Is it at least as likely as not (probability of 50 percent or greater) that the Veteran's lumbar spine disorder had its onset during, or is otherwise related to, the Veteran's military service? The examiner should address the Veteran's contention that his lumbar spine disorder is as a result of a motor vehicle accident occurring in March 1969, during active service. (B) Is it at least as likely as not (probability of 50 percent or greater) that the Veteran's cervical spine disorder had its onset during, or is otherwise related to, the Veteran's military service? The examiner should address the Veteran's contention that his cervical spine disorder is as a result of a motor vehicle accident occurring in March 1969, during active service. (C) Is it at least as likely as not (probability of 50 percent or greater) that the Veteran's left and right hip disorders had its onset during, or is otherwise related to, the Veteran's military service? The examiner should address the Veteran's contention that his left and right hip disorders are as a result of a motor vehicle accident occurring in March 1969, during active service. (D) Is it at least as likely as not (probability of 50 percent or greater) that the Veteran's left ankle disorder had its onset during, or is otherwise related to, the Veteran's military service? The examiner should address the Veteran's contention that his left ankle disorder is as a result of a motor vehicle accident occurring in March 1969, during active service. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Following the receipt of outstanding records, obtain an etiology opinion as to the Veteran's claimed hypertension from an appropriate medical professional. The record must be made available to the examiner. The need for a physical examination of the Veteran is left to the discretion of the examiner. The examiner should respond to the following question: Is it at least as likely as not (probability of 50 percent or greater) that the Veteran's hypertension had its onset during, or is otherwise related to, the Veteran's military service, to include his exposure to herbicide agents? The examiner should address the significance, if any, of the Veteran's service in the Republic of Vietnam and herbicide agent exposure. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Following the receipt of outstanding records, obtain an etiology opinion as to the Veteran's claimed cardiovascular disorder from an appropriate medical professional. The record must be made available to the examiner. The need for a physical examination of the Veteran is left to the discretion of the examiner. The examiner should first diagnose any current cardiovascular conditions present upon examination. Then, the examiner should respond to the following questions: (A) The examiner should specifically indicate whether any of the Veteran's diagnosed cardiovascular disorders constitute ischemic heart disease. (B) Is it at least as likely as not (probability of 50 percent or greater) that any currently present cardiovascular disorder had its onset during, or is otherwise related to, the Veteran's military service, to include his presumed exposure to herbicide agents? The examiner should address the significance, if any, of the Veteran's service in the Republic of Vietnam and herbicide agent exposure. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 5. Following the receipt of outstanding records, obtain an etiology opinion as to the Veteran's claimed cataracts from an appropriate medical professional. The record must be made available to the examiner. The need for an additional examination of the Veteran is left to the discretion of the examiner selected to write the addendum opinion. The examiner should respond to the following questions: (A) Is it at least as likely as not (probability of 50 percent or greater) that the cataracts had its onset during, or is otherwise related to, the Veteran's military service, to include the Veteran's presumed exposure to herbicide agents?. The examiner should address the significance, if any, of the Veteran's service in the Republic of Vietnam. (B) Is it at least as likely as not (probability of 50 percent or greater) that the cataracts were caused or permanently aggravated by his service-connected diabetes mellitus? A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mariah N. Sim, 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.