Citation Nr: 21041928 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-55 688 DATE: July 10, 2021 ORDER The appeal as to the claim of entitlement to service connection for lumbar spine disorder, to include as secondary to the service-connected right shoulder disability, is denied. The appeal as to the claim of entitlement to an initial evaluation in excess of 20 percent for service-connected right shoulder disability is denied. REMANDED The appeal as to the claim of entitlement to service connection for left shoulder disorder, to include as secondary to the service-connected right shoulder disability and/or cervical spine disorder, is remanded. The appeal as the claim of entitlement to service connection for hypertension, to include as secondary to the service-connected somatic disorder, is remanded. The appeal as the claim of entitlement to service connection for erectile dysfunction disorder, to include as secondary to the service-connected somatic disorder, is remanded. The appeal as to the claim of entitlement to service connection for a lung disorder, (claimed as pulmonary nodule) to include as due to asbestos exposure, is remanded. The appeal as to the claim of entitlement to service connection for right ankle disorder is remanded. The appeal as the claim of entitlement to service connection for cervical spine disorder, to include as secondary to the service-connected right shoulder disability, is remanded. FINDINGS OF FACT 1. The Veteran does not have a current lumbar spine disorder. 2. The Veteran's right shoulder disability has been manifested by flexion to 90 degrees, abduction to 55 degrees, external rotation to 40 degrees, and internal rotation to 65 degrees. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for lumbar spine disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for an initial evaluation in excess of 20 percent for a right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.321, 4.71a, Diagnostic Code 5201 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from November 1974 to November 1977. His service was under honorable conditions. These matters are on appeal from September 2015 and August 2016 rating decisions. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Legal Criteria Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (finding service connection presupposes a current diagnosis of the condition claimed). The requirement that a current disability be present is satisfied, "when a claimant has a disability at the time a claim for VA disability compensate on is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim." McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 1. Entitlement to service connection for lumbar spine disorder, to include as secondary to the service-connected right shoulder disability. The Veteran contends that his current lumbar spine disorder is related to active service. Service treatment records are negative for complaints of, treatment for, or diagnoses of a lumbar spine disorder. Post-service VA and private treatment records are negative for complaints of, treatment for, or diagnoses of a lumbar spine disorder. In this regard, the Veteran underwent a VA examination in October 2019, during which the examiner found that the was no current diagnosis of a lumbar spine disorder. Based on the evidence of record, the Board concludes that the Veteran does not have a diagnosis of a lumbar spine disability. As such, the first element of a service connection claim is not met. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). The Board is cognizant of the recent holding in Saunders v. Wilkie which stated that, where pain causes functional impairment, a disability for VA compensation purposes exists, even if there is no underlying diagnosis. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). In sum, pain alone resulting in functional impairment is in fact a disability, and should not be summarily discounted as a bar to benefits based on a finding of no current diagnosis. However, even in light of Saunders, the Veteran still does not have a present disability pertaining to the lumbar spine as he does not have a diagnosis, and the October 2019 VA examiner noted that his pain did not result in any functional loss or functional impairment. Furthermore, his VA treatment records do not reflect complaints pertaining to lumbar spine. Based on such evidence, the Board finds that this case is distinguished from Saunders. While the Veteran believes he has a current lumbar spine disability, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education to diagnose physical disabilities. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. Accordingly, the Board finds that the probative evidence is against finding that the Veteran has a current lumbar spine disability. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine does not apply, and service connection must be denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Increased Rating General Legal Criteria Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2020). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 3.321 (a), 4.1 (2020). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In accordance with 38 C.F.R. §§ 4.1, 4.2 (2020) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disabilities at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability. In both initial rating claims and normal increased rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). VA must consider all favorable lay evidence of record. 38 U.S.C. § 5107 (b); Caluza v. Brown, 7 Vet. App. 498 (1995). The Veteran is competent to testify regarding the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2020). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2020). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45 (2020). The intent of the Rating Schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59 (2020). In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. 2. Entitlement to an evaluation in excess of 20 percent for service-connected right shoulder disability. The Veteran contends that his right shoulder disability is more severe than his current 20 percent evaluation, that is rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5201. The evidence of record demonstrates that the Veteran is right-handed, and his disability is his right shoulder. Thus, schedular ratings for the major shoulder are for application. 38 C.F.R. § 4.69 (2020). Limitation of motion of the major arm at shoulder level warrants a 20 percent disability rating; limitation of motion of the major arm midway between side and shoulder level warrants a 30 percent disability rating; and limitation of motion of the major arm to 25 degrees from side warrants a 40 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal ranges of upper extremity motion are flexion from zero to 180 degrees, abduction from zero to 180 degrees, and internal and external rotation from zero to 90 degrees. 38 C.F.R. § 4.71, Plate I. Upon review, the evidence of record shows that a rating in excess of 20 percent is not warranted. The Veteran underwent a VA examination in September 2015. The examination revealed right shoulder tenderness and pain upon palpation of the joint. Range of motion testing showed right shoulder flexion to 180 degrees, abduction to 180 degrees, external rotation to 90 degrees, and internal rotation to 70 degrees. There was no evidence of loss of range of motion upon repetition testing. There was evidence of additional functional loss caused by pain, fatigue, and weakness. In this regard, the examiner indicated that the functional loss could not be described in terms of range of motion. With respect to flare-ups, pain, weakness, fatigability or incoordination did not limit functional ability. The examiner diagnosed status post fracture right clavicle, and right shoulder arthrosis. These measurements do not support a 30 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. An April 2017 VA outpatient treatment records notes the Veteran's report of chronic right shoulder pain. The Veteran underwent a VA examination in October 2019. The examination did not demonstrate right shoulder tenderness and pain upon palpation of the joint. Range of motion testing showed right shoulder flexion to 90 degrees, abduction to 55 degrees, external rotation to 40 degrees, and internal rotation to 65 degrees. There was no evidence of loss of range of motion upon repetition testing. With respect to repeated use over time, pain, weakness, fatigability or incoordination did not limit functional ability. With respect to flare-ups, pain, weakness, fatigability or incoordination did not limit functional ability. The examiner diagnosed status post fracture right clavicle, right shoulder strain, and right shoulder arthrosis. These measurements do not support a 30 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. Consideration of functional loss and impairment does not lead to a higher rating. 38 C.F.R. §§ 4.40, 4.45, 4.59; see Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011); Deluca v. Brown, 8 Vet. App. 202, 204-06 (1995). During the September 2015 examination, the Veteran reported pain and tenderness and flare-ups of his right shoulder. The examiner accounted for the Veteran's symptoms and the Veteran could perform repetitive testing during the September 2015 examination, which revealed no additional functional loss or limitation of motion. Although there was evidence of additional functional loss caused by pain, the range of motion findings do not support a higher 30 percent evaluation. Similarly, the October 2019 VA examiner accounted for the Veteran's symptoms and the Veteran could perform repetitive testing during the October 2019 examination, which revealed no additional functional loss or limitation of motion. There was no evidence of additional functional loss caused by pain. In addition, the frequency and severity of the Veteran's reported symptoms do not rise to the level needed for a 30 percent rating. Indeed, the range of motion noted on the September 2015 VA examination is at least 20 degrees greater than what is needed for a 30 percent rating. Likewise, the range of motion noted on the October 2019 VA examination is at least 15 degrees greater than what is needed for a 30 percent rating. There is no other evidence in the record which shows that the Veteran meets the criteria required for a higher rating. Further, the Board has considered the lay evidence offered by the Veteran in the form of correspondence, in addition to the medical evidence cited above. In this regard, the Board acknowledges the Veteran's consistent report of pain, swelling, and difficulty lifting. However, even affording the lay statements full competence and credibility, the evidence simply does not show entitlement to a higher evaluation under any applicable diagnostic code. Accordingly, an initial rating in excess of 20 percent for right shoulder disability is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for left shoulder disorder, to include as secondary to the service-connected right shoulder disability and/or cervical spine disorder. When the Board last reviewed the claim in December 2018, it noted a March 2017 private MRI report of the left shoulder, which indicates mild degenerative changes of the AC joint, severe tendinopathy of the rotator cuff, and severe glenohumeral arthrosis. The Board found that a VA examination and opinion were necessary in order to adjudicate the claim. In an October 2019 opinion, a VA examiner found that the Veteran's current left shoulder pain was not related to his active service. In providing the opinion, the examiner noted that the service treatment records were negative for complaints of, and treatment for, a left shoulder injury or disorder. The examiner concluded that there was no objective evidence supporting the premise that the Veteran's service-connected right shoulder caused the current left shoulder disorder. The October 2019 VA examiner's opinion is inadequate to adjudicate the claim, as the examiner failed to consider the Veteran's ongoing assertions that his left shoulder pain began during service, and that it progressively worsened. Further, the examiner failed to provide an opinion with respect to the current left shoulder disorders, to include, mild degenerative changes of the AC joint, severe tendinopathy of the rotator cuff, and severe glenohumeral arthrosis. In addition, the Board notes that the December 2018 decision directed the RO to remand for a VA examination and medical opinion, not a medical opinion. As such, the Board finds that its directives were not complied with, therefore, further action by the Board would be in violation of the holding in Stegall v. West, 11 Vet. App. 268, 270-1 (1998). Accordingly, the issue must be remanded for a VA examination and adequate VA medical opinion. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 2. Entitlement to service connection for hypertension, to include as secondary to the service-connected somatic disorder. See argument Below at 3 3. Entitlement to service connection for erectile dysfunction disorder, to include as secondary to the service-connected somatic disorder. With respect to the claimed hypertension and erectile dysfunction disorders, when the Board last reviewed the claim in December 2018, it noted that the April 2017 VA examiner did not address the question of whether the disorders were caused or aggravated by the service-connected somatic disorder. The Veteran underwent VA examinations in October 2019, during which the examiner found that the current hypertension and erectile dysfunction disorders were not related to the Veteran's active service. In providing the opinions, the examiner noted that there was no evidence of complaints of, or treatment for hypertension or erectile dysfunction during service. Regarding secondary service connection, the examiner found that the current hypertension and erectile dysfunction disorders were not caused by the service-connected somatic disorder. The examiner did not opine as to whether the disorders were aggravated by the service-connected somatic disorder. The October 2019 VA examiner's opinion is inadequate to adjudicate the claim, as the examiner failed to provide an adequate rationale (or any rationale) for the negative secondary opinion with respect to causation, Further, the examiner failed to provide a medical opinion addressing aggravation. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Therefore, these issues must be remanded for adequate VA medical opinions. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 4. Entitlement to service connection for a lung disorder (claimed as pulmonary nodule), to include as due to asbestos exposure. The Veteran contends that his current lung disorder is the result of active service onboard the USS Pawcatuck (AO-108), as a result of his duties, which exposed him to jet fuel and mucking tanks during. Service treatment records include a July 1975 record that notes the Veteran reported that he suffered from colds once or twice a year. He also reported that he was congested; bronchitis was assessed. A February 1976 record notes the Veteran had congestion in his right lung; influenza and bronchitis were assessed. Post-service treatment records include a January 2015 VA CT scan of the chest that shows a small 2mm noncalcified right lower lobe pulmonary nodule. The report of an April 2017 VA examination demonstrates normal lung volumes. Examination was negative for evidence of acute cardiopulmonary disease, pleural effusion, pneumonia, edema, or osseus abnormalities. Upon examination, the examiner found that the Veteran did not have a current diagnosis of a lung condition, other than a small 2mm noncalcified right lower lobe pulmonary nodule, noted on chest examination in January 2015, which he attributed to a current diagnosis of obstructive sleep apnea. The examiner opined that the current pulmonary nodule was less likely than not related to active service. In providing the opinion, the examiner noted that the service treatment records were negative for a chronic lung condition, and the Veteran's military occupational specialties were associated with minimal probability of asbestos exposure. In its December 2018 decision, the Board found the April 2017 VA examiner's opinion inadequate to adjudicate the claim, as the examiner based his opinion on a lack of verification of asbestos exposure, and a lack of verification in service treatment records. Further, the examiner failed to address the Veteran's contentions regarding exposure to jet fuel and mucking tanks. The report of an October 2019 VA examination shows normal lung volumes. There was no evidence of acute cardiopulmonary disease, pleural effusion, pneumonia, edema, or osseus abnormalities. Pulmonary Function Testing, namely, pre-bronchodilator results, were normal. Upon examination, the examiner diagnosed a benign pulmonary nodule. The examiner opined that the spot on the Veteran's right lung was determined to be a "non-issue." The Board finds the aforementioned VA opinions inadequate to adjudicate the claim, as the examiners failed to provide a sufficient rationale for their negative direct opinions. Moreover, while the October 2019 VA examiner found the Veteran's current pulmonary nodule to be a |non-issue," it is in fact, a current lung disorder. Accordingly, this issue must be remanded for an adequate VA medical opinion. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Finally, regarding the theory of asbestos exposure, VA must attempt to verify the Veteran's claimed asbestos exposure during his active service, to include while serving aboard the USS Pawcatuck (AO-108). Thus, on remand, the AOJ must obtain all pertinent ship logs for the USS Pawcatuck (AO-108), and then attempt to verify, through all official sources, any exposure of the Veteran to asbestos in service. 5. Entitlement to service connection for right ankle disorder. With respect to the claimed right shoulder disorder, when the Board last reviewed the claim, it found that a VA examination and opinion were necessary in order to adjudicate the claim. The Veteran underwent a VA examination in October 2019, during which a right ankle strain was diagnosed. At the time, the Veteran reported that his right ankle condition began in 1975 during service, when he fell and broke his right shoulder collarbone and injured his ankle. He further reported that he injured his right ankle a second time during service while doing a required run that he was unable to complete. The Veteran reported that he also injured his ankle multiple times going up and down ladders on the ship. The Veteran asserted that he has experienced pain and swelling of his right ankle since the in-service injuries. Upon examination, the examiner found that the current right ankle strain was not related to the Veteran's active service. In providing the opinion, the examiner noted that the service treatment records were negative for complaints of, or treatment for a right ankle injury. The October 2019 VA examiner's opinion is inadequate to adjudicate the claim, as the examiner failed to consider the Veteran's ongoing assertions that his right ankle pain began following his in-service right shoulder injury, and that it progressively worsened. Therefore, this issue must be remanded for an adequate VA medical opinion. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 6. Entitlement to service connection for cervical spine disorder, to include as secondary to the service-connected right shoulder disability. Regarding the claimed cervical spine disorder, when the Board last reviewed the claim, it found that a VA examination and opinion were necessary in order to adjudicate the claim. The Veteran underwent VA examinations in October 2019. Upon examination, the examiner diagnosed cervicalgia. The examiner opined that the current disorder was not caused or aggravated by the service-connected right shoulder disability because the file "shows no objective evidence supporting the premise." The Board finds the October 2019 VA opinion inadequate to adjudicate the claim, as the examiner failed to provide a sufficient rationale for his negative opinions with respect to causation and aggravation. In addition, the examiner failed to consider the Veteran's ongoing assertions that his cervical spine pain began following his in-service right shoulder injury, and that it progressively worsened. Therefore, this issue must be remanded for an adequate VA medical opinion. Id. As this claim is being remanded, updated VA outpatient treatment records should also be obtained. 38 C.F.R. § 3.159. The matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim, to include VA outpatient treatment records from April 2020, to the present. If any requested records are unavailable, or the search for such records otherwise yields negative results, that fact should clearly be documented in the record and the Veteran so notified in accordance with 38 C.F.R. § 3.159(e). All steps taken to attempt to obtain the above records should clearly be documented in the record. 2. Request all pertinent ship logs for the USS Pawcatuck AO-108. All requests for records and their responses must be associated with the record. 3. Take all necessary steps to verify, THROUGH OFFICIAL SOURCES, any in-service exposure of the Veteran to Asbestos while serving aboard the USS Pawcatuck AO-108 during his active service aboard the Ship. 4. Schedule the Veteran for a VA examination before an appropriate physician to determine the etiology of any current left shoulder disorder present during the period on appeal, to include mild degenerative changes of the AC joint, severe tendinopathy of the rotator cuff, and severe glenohumeral arthrosis. The examiner must review the record, to include service treatment records, VA and private treatment records, lay statements and the Veteran's statements. The examiner must also consider the Veteran's documented medical history, assertions, and reported symptoms. All indicated studies should be completed, and all clinical findings reported in detail. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that any current left shoulder disorder, to include mild degenerative changes of the AC joint, severe tendinopathy of the rotator cuff, and severe glenohumeral arthrosis, manifested during, or as a result of, active military service. In providing the opinion, the examiner must discuss the contemporaneous private diagnoses of mild degenerative changes of the AC joint, severe tendinopathy of the rotator cuff, and severe glenohumeral arthrosis, as well as the Veteran's assertions that he has experienced left shoulder pain since active service. For purposes of the opinions, the examiner should assume that the Veteran is a credible historian. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. 5. Once the record is developed to the extent possible, all pertinent evidence of record must be made available to and reviewed by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the hypertension disorder present during the period of the claim. The examiner must address the following: Is it at least as likely as not (i.e., at least 50 percent probable) that the current hypertension disorder is etiologically related to the Veteran's active service? If not, the examiner should state a medical opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the disorder was caused or aggravated by his service-connected somatic disorder. In providing the opinion, the examiner must discuss the contemporaneous private treatment records and VA examination reports that note diagnoses of hypertension. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. Another examination of the Veteran should only be performed if deemed necessary by the physician providing the opinions. 6. Once the record is developed to the extent possible, all pertinent evidence of record must be made available to and reviewed by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the erectile dysfunction disorder present during the period of the claim. The examiner must address the following: Is it at least as likely as not (i.e., at least 50 percent probable) that the current erectile dysfunction disorder is etiologically related to the Veteran's active service? If not, the examiner should state a medical opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the disorder was caused or aggravated by his service-connected somatic disorder. In providing the opinion, the examiner must discuss the contemporaneous private treatment records and VA examination reports that note diagnoses of erectile dysfunction. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. Another examination of the Veteran should only be performed if deemed necessary by the physician providing the opinions. 7. Once the record is developed to the extent possible, all pertinent evidence of record must be made available to and reviewed by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the lung disorder present during the period of the claim, to pulmonary nodule. The examiner must address the following: Is it at least as likely as not (i.e., at least 50 percent probable) that the current pulmonary nodule disorder is etiologically related to the Veteran's active service? (to include any confirmed exposure to asbestos). In providing the opinion, that examiner must discuss the July 1975 service treatment record that notes the Veteran sought treatment for congestion, and bronchitis was assessed; and a February 1976 record that notes the Veteran had congestion in his right lung, and influenza and bronchitis were assessed. The examiner must also discuss the contemporaneous private treatment records and VA examination reports that note diagnoses of pulmonary nodule. The examiner must discuss the Veteran's assertions, that his exposure to jet fuel and mucking tanks during active service, resulted in his current pulmonary disorders. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. Another examination of the Veteran should only be performed if deemed necessary by the physician providing the opinions. 8. Once the record is developed to the extent possible, all pertinent evidence of record must be made available to and reviewed by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the right ankle disorder present during the period of the claim, to right ankle strain. The examiner must address the following: Is it at least as likely as not (i.e., at least 50 percent probable) that the current right ankle strain is etiologically related to the Veteran's active service? In providing the opinion, that examiner must discuss the contemporaneous private treatment records and VA examination reports that note diagnoses of right ankle strain. The examiner must discuss the Veteran's assertions, that his right ankle pain began following his in-service right shoulder injury, and that it progressively worsened. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. Another examination of the Veteran should only be performed if deemed necessary by the physician providing the opinions. 9. Once the record is developed to the extent possible, all pertinent evidence of record must be made available to and reviewed by an appropriate VA physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following a review of the record, the physician should state a medical opinion with respect to the cervical spine disorder present during the period of the claim. The examiner must address the following: Is it at least as likely as not (i.e., at least 50 percent probable) that the current cervicalgia disorder is etiologically related to the Veteran's active service? If not, the examiner should state a medical opinion as to whether it is at least as likely as not (i.e., at least 50 percent probable) that the disorder was caused or aggravated by his service-connected right shoulder disorder. In providing the opinion, the examiner must discuss the VA examination report that notes a diagnosis of cervicalgia, as well as the Veteran's assertions of neck pain since he injured his right shoulder during active service. A complete rationale for all opinions offered must be provided. If the examiner is unable to provide any required opinion, the examiner should fully explain why this is the case. Likewise, if the examiner cannot provide an opinion without resorting to mere speculation, the examiner shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. Another examination of the Veteran should only be performed if deemed necessary by the physician providing the opinions. 10. The AOJ should ensure that the Veteran is provided with adequate notice of the date and place of all scheduled examinations. A copy of all notifications, including the address where the notice was sent, must be associated with the record if the Veteran fails to report for any examination. The Veteran is to be advised that failure to report for a scheduled VA examination without good cause may have adverse effects on his claim. 11. Then, the AOJ should readjudicate the issues on appeal. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he and his representative should be provided a supplemental statement of the case and an appropriate period for response before the case is returned to the Board for further appellate action. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sara Schinnerer, 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.